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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700065
Report Date: 12/11/2023
Date Signed: 12/11/2023 11:59:38 AM

Document Has Been Signed on 12/11/2023 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WILTON STABLESFACILITY NUMBER:
342700065
ADMINISTRATOR:KOLU G SOKODOLOFACILITY TYPE:
735
ADDRESS:11119 MANN ROADTELEPHONE:
(916) 687-4548
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY: 4CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ramone RomoTIME COMPLETED:
10:30 AM
NARRATIVE
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LPA Jensen arrived at facility at 9:15am unannounced to conduct a case management for deficiencies observed during the course of a complaint investigation under complaint control number 27-AS-20230814164513. LPA Jensen met with Ramone Romo and explained the purpose of today's visit.

While investigating the above listed complaint LPA Jensen reviewed LIC 405's and receipt's for Resident R1. LPA Jensen observed discrepancies in accounting for the period from 20176 to July 23, 2023. The discrepancies included transactions for which there was no corresponding receipt, receipts for which there was no corresponding ledger and transactions that had a ledger for incorrect amounts. Based on an interview with the Regional Manager, there has been a change in the Administrator of Record and all transactions prior to July 23, 2023 would have been the responsibility of the prior Administrator. The Regional Manager also stated that he is unable to explain the discrepancies at this time.

Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties of administrative action.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 12/11/2023 11:59 AM - It Cannot Be Edited


Created By: Maja Jensen On 12/11/2023 at 09:55 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WILTON STABLES
FACILITY NUMBER: 342700065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited
CCR
80026(h)(1)

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Each licensee shall maintain accurate records of accounts of cash resources, ...including, but not limited to the following:
Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting,
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The Licensee agrees to reconcile the Personal a d Incidental fund records for all current clients in care and will provide evidence of such to LPA Jensen by the POC due date.
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with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement was not met as evidenced by: Based on LPA Jensen's review of LIC 405's and receipts for R1. This poses a potential risk for the health, safety and personal rights of residents in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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