<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700945
Report Date: 12/21/2022
Date Signed: 12/21/2022 01:42:14 PM

Document Has Been Signed on 12/21/2022 01:42 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:WELLCARE HOMES 3FACILITY NUMBER:
342700945
ADMINISTRATOR:CAMALIG, YVONNE K.FACILITY TYPE:
737
ADDRESS:10799 SIMMERHORN RD.TELEPHONE:
(916) 639-0091
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: DATE:
12/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vonne Camalig, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/21/2022, Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced case management incident inspection visit regarding suspicion of physical abuse of staff towards resident. LPA explained purpose of visit with Administrator Vonne Camalig for an incident (Incident 1) that occurred on 11/29/22. Based on staff interview and documentation, LPA determined that Administrator followed procedure and regulation to protect the safety of residents including communicating with police, ombudsman and licensing per regulatory requirements.

Over the course of the visit, LPA and Administrator discussed another incident (Incident 2) that occurred on 11/14/22. Based on staff interviews and facility documentation, it was determined that S2 struck R1 in the kitchen during a resident behavioral episode. S2 was dismissed and additional training provided. Though the incident occurred on 11/14/22, incident reports were not submitted until 12/05/22.

The following deficiencies were cited per California Code of Regulations, Title 22, Division 6, Chapter 8. (See LIC809-D)

An exit interview was conducted with Administrator and a copy of this report along with appeal rights and civil penalty was provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/21/2022 01:42 PM - It Cannot Be Edited


Created By: Renee Campbell On 12/21/2022 at 12:55 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: WELLCARE HOMES 3
FACILITY NUMBER: 342700945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited
CCR
80061

1
2
3
4
5
6
7
80061 Reporting Requirements (d) Any .. physical abuse that does not result in serious bodily injury … shall be reported to . . ombudsman ...licensing agency, and ... law enforcement agency within ... (24) hours ...This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will conduct staff training on regulation 80061 and submit proof of completed training to LPA by POC due date

Licensee will read and provide a signed statement of understanding of regulation 80061.
8
9
10
11
12
13
14
Based on…. Interviews and record review, the licensee did not ensure a full incident report was submitted within 24 hrs.
8
9
10
11
12
13
14
Type B
12/29/2022
Section Cited
CCR80072

1
2
3
4
5
6
7
Personal Rights 80072 (a)(3)
To be free from corporal or unusual punishment... or other actions of a punitive nature, including but not limited to: interference with the daily living functions….This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Staff was disciplined accordingly and licensee proivded additional training for staff. Proof of training should be provided to licensing by POC date at renee.campbell@dss.ca.gov
8
9
10
11
12
13
14
Interviews and records reviewed confirmed that staff hit resident with object.
8
9
10
11
12
13
14
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:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2