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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700065
Report Date: 05/05/2023
Date Signed: 05/08/2023 04:28:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/08/2023 04:28 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:WILTON STABLESFACILITY NUMBER:
342700065
ADMINISTRATOR:TANYA BARRETOFACILITY TYPE:
735
ADDRESS:11119 MANN ROADTELEPHONE:
(916) 687-4548
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY: 4CENSUS: 3DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:S. Watson/ and T. Barreto over the telephoneTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff. The facility is without an active Administrator, The current certificate for Tanya Barreto expired on 5/1/2023.

LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. During the tour LPA observed missing screen in the back yard by the garage, tall grass in the front of the facility and in the backyard, the exit door from the garage to the back yard is blocked with a sign saying do not use (fire clearance violation), broken shower grab bar, extreme dust build up on the vents for the filters in the and a broken toilet seat cover. LPA also observed unlocked toxin in R1's room and in the top hall cabinet (The locking device is broken and cannot lock) .

LPA and Staff measured the hot water temperature in residents bathroom at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguisher and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs.

First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 4/2023. Deficiencies cited with civil penalties assessed.

Exit interview conducted and appeal rights given
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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 05/08/2023 04:28 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/05/2023 at 11:24 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: WILTON STABLES
FACILITY NUMBER: 342700065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2023
Section Cited
CCR
85064(b)

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All adult residential facilities shall have a certified administrator. LPA observed Tanya Barreto
administrator's certificate to be expired(5/1/2023).
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Administrator shall obtain a current valid administrators certificate. This shall be done within 60 days. Facility shall forward a copy to the LPA to clear this deficiency.
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The facility must appoint an alternate administrator at the facility by close of business on 5/6/2023
Type B
05/19/2023
Section Cited
CCR80087(a)

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Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

LPA observed missing screen in the back yard by the garage, tall grass in the front of the facility and in the backyard, the exit door from the garage to the back yard is blocked with a sign saying do not use, broken shower grab bar,
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The facility will clean, fix, replace or remove any items cited during this inspection.
The facility will submit photos and receipt for repairs by POC date 5/19/2023
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extreme dust build up on the vents for the filters in the and a broken toilet seat cover.
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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: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2023 04:28 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/05/2023 at 12:39 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: WILTON STABLES
FACILITY NUMBER: 342700065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2023
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
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The facility will remove the cabinet from blocking the door and submit a plan for the repair or replacement of the door leading out of the garage by POC Date 5/6/2023
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This requirement was not met as evidenced by observation the facility is blocking the exit (photo taken) leading out of the garage.
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Type A
05/06/2023
Section Cited
CCR80087(g)(1)

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80087(g)(1) Buildings and Grounds ..Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Administrator will conduct an in-service training with staff regarding proper storage for toxins and items that may cause a danger. Curriculum and date of training to be sent into CCL on 05/06/2023.
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LPA also observed unlocked toxin in R1's room and in the top hall cabinet (The locking device is broken and cannot lock) . Toxins unlocked pose an immediate health and safety risk to residents.
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If additional time is need please request by email with expected timelines.
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: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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