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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700266
Report Date: 05/07/2024
Date Signed: 05/07/2024 01:08:31 PM

Document Has Been Signed on 05/07/2024 01:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CABRERA'S GUEST HOMEFACILITY NUMBER:
342700266
ADMINISTRATOR/
DIRECTOR:		CABRERA, DIGNAFACILITY TYPE:
735
ADDRESS:1229 SOUTH HARRISON STTELEPHONE:
(209) 598-7588
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Digna CabreraTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 5-7-24 at 11:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident reported on 3-18-24. LPA met with Administrator Digna Cabrera and explained the purpose of the visit. LPA reviewed incident reported dated 3-18-24 with Administrator, physician's report for resident1 (R1), individualized program plan for R1,hospital discharge paperwork, and conducted brief interview with Administrator. Based on incident report and interview, on 3-16-24 at approximately 9:50pm, resident1 (R1) was observed by staff to be shaking with slurred speech and tongue out of mouth. Incident report also revealed R1 told staff she was feeling tired and experienced a headache. Incident report states staff immediately checked R1's blood sugar which was noted as low. Staff then gave R1 a snack and juice due to low blood sugar, and called 9-1-1 approximately 15-20 minutes thereafter. Interview conducted revealed R1 was feeling lethargic in addition to the other symptoms noted above, but not unconsciousness. Emergency personnel arrived and took R1 to local hospital. R1 was discharged on 3-16-24 back to facility with no new medication. A review of R1's individualized program plan (IPP) indicates R1 has a history of seizure disorder. A review of R1's seizure monitoring record indicates R1 has not experienced a seizure since admission.

As a result of today's case management, citation is issued under Title 22, Division 6. An exit interview was conducted with Digna Cabrera and a copy of this report was provided to Digna. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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 05/07/2024 01:08 PM - It Cannot Be Edited


Created By: Michael Bilger On 05/07/2024 at 12:46 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CABRERA'S GUEST HOME
FACILITY NUMBER: 342700266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. The requirement was not met as evidenced by:
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Licensee will ensure completed staff training on emergency response - training to include appropriate timing for calling 911 and recognizing signs and symptoms of medical emergencies. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA by 5-22-24.
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Based on interview and record review, Licensee did not ensure timely and appropriate medical attention for R1 during a medical emergency. This posed an immediate health and safety risk to resdient 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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