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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202977
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:32:27 PM

Document Has Been Signed on 12/12/2024 12:32 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,
, CA
FACILITY NAME:C AND D'S GUEST HOME #5FACILITY NUMBER:
247202977
ADMINISTRATOR/
DIRECTOR:		DOBBINS, CHANTE L.FACILITY TYPE:
735
ADDRESS:2960 PALOMINO LANETELEPHONE:
(209) 358-8029
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 6CENSUS: 5DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator, Barbara CowardTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Barbara Coward, Continual Administrator's Certification Shirley Davis for expires 01/11/2025. There are currently 5 residents who reside at this home LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 110 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

Staff 1 does not have a file available at the facility for review.
LIC610D Emergency Disaster Plan is not available for review.
Resident 1's cash resources has not been updated since 10/2024.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with facility staff Barbara Coward, and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 12/12/2024 12:32 PM - It Cannot Be Edited


Created By: Sarah Hurt On 12/12/2024 at 12:10 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
,
, CA

FACILITY NAME: C AND D'S GUEST HOME #5
FACILITY NUMBER: 247202977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Resident 1's cash resource log has not been updated since 10/2024. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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Licensee will provide updated cash resource log, and bank statement from 09/2024 to current for Resident 1 to LPA by POC date of 12/26/2024.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the facility staff could not provide LIC610D Emergency Disaster Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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Licensee will provide LIC610D Emergency Disaster Plan to LPA by POC date of 12/26/2024.
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:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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