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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057001380
Report Date: 12/15/2021
Date Signed: 12/16/2021 04:31:02 PM

Document Has Been Signed on 12/16/2021 04:31 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:WATCH-GOLDSTRIKEFACILITY NUMBER:
057001380
ADMINISTRATOR:CHRISTINA GARIBAYFACILITY TYPE:
735
ADDRESS:342 GOLDSTRIKE ROADTELEPHONE:
(209) 754-3773
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 12CENSUS: 7DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Christina Garibay, AdministratorTIME COMPLETED:
11:45 AM
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On 12/15/2021 around 8:00am, Licensing Program Analyst (LPA) T. White spoke with Administrator, Christina Garibay regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:35am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Christina Garibay and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 12 clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, backyard and front yard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 115.1 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day non-perishable and 2-day perishable foods.

LPA observed sprinkler system throughout the facility. Administrator stated sprinkler system was last tested on 07/22/2021. Carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on March 05, 2021. Mitigation observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 12/03/2021. LPA reviewed 4 client files and 2 staff files.

- LPA observed 1 out of 5 missing drawers in Room #6 bedroom.
- LPA observed drainage in Room #1 bathroom not operating properly.

Report continues on 809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WATCH-GOLDSTRIKE
FACILITY NUMBER: 057001380
VISIT DATE: 12/15/2021
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The following forms to be updated and submitted to CCLD by 12/24/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and Appeal Rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2021 04:31 PM - It Cannot Be Edited


Created By: Treana White On 12/15/2021 at 10:57 AM
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: WATCH-GOLDSTRIKE
FACILITY NUMBER: 057001380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 80087(a). LPA observed drainage not in operable condition and 1 out of 5 drawer missing in clients bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2021
Plan of Correction
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Administrator agreed to repair drawer in clients bedroom and repair drain in client's bathroom. Administrator agreed to submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021


LIC809 (FAS) - (06/04)
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