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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 03/28/2022
Date Signed: 03/29/2022 05:37:52 PM

Document Has Been Signed on 03/29/2022 05:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:STETSON COURT LIVINGFACILITY NUMBER:
397005195
ADMINISTRATOR:GAOIRAN, CHRISTIANFACILITY TYPE:
740
ADDRESS:3913 STETSON COURTTELEPHONE:
(408) 876-9445
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Geline ArtuzTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Geline Artuz and explained the purpose of the visit.

LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, medication rooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA was not able to review 2 resident and 2 staff files. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed during this visit. LPA will return to review files and complete the inspection and write citations. Exit interview held with Staff.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2022 05:37 PM - It Cannot Be Edited


Created By: Albert Johnson On 03/29/2022 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: STETSON COURT LIVING
FACILITY NUMBER: 397005195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.

This requirement is not met as evidenced by:
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Licensee will obtain the criminal record clearance transferfor S1. Licensee has agreed to not allow said staff member or potential new hire to be present in the facility without first obtaining a criminal record clearance transfer. Licensee to review the cited regulation to ensure continued compliance.
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Based on LPA observation and record review licensee failed to ensure S1 obtained a criminal record clearance transfer prior to starting.
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*****Immediate Civil Penalty Assessed******

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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