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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001671
Report Date: 10/23/2023
Date Signed: 10/23/2023 09:01:58 PM

Document Has Been Signed on 10/23/2023 09:01 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:DOUG & DEBBIE MONDAY'S CARE HOME #2FACILITY NUMBER:
347001671
ADMINISTRATOR:DOUGLAS MONDAYFACILITY TYPE:
735
ADDRESS:13118 CHRISTENSEN ROADTELEPHONE:
(209) 745-4911
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 6CENSUS: 5DATE:
10/23/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Debra Monday, Catrina Vaden, and Amanda MondayTIME COMPLETED:
09:15 PM
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Sacramento South Regional Office Staff, Assistant Program Administrator (APA) Stacy Barlow, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio, Investigator Andrew Murrow arrived unannounced to the facility for the purpose of delivering a Temporary Suspension Order (TSO) on today's date of 10/23/2023. The TSO will be effective as of 11:45 PM on 10/23/23. The Regional Office staff were met by facility staff and Licensee Debra Monday.

LPM Richardson, LPA Valerio, APA Barlow, and Investigator Murrow toured the facility to ensure health and safety of resident in care. The facility was observed to have several deficiencies throughout exterior and interior of the facility. Pictures were obtained for reference. During the tour, Licensee Debra denied licensing access to the staff area of the facility. This facility is being cited per HSC Section 1533(a). Due to a repeat violation, the licensee was made aware that civil penalties are being assessed on today's date, 10/23/23, in the amount of $250.00.

APA, Stacy Barlow went over the TSO paperwork with Licensee Debra Monday, Facility Staff, and residents. APA Stacy Barlow served five (5) residents with the TSO paperwork on today's date. APA Barlow provided Licensee with the Appeal/ Notice of Defense process.

At 6:45 PM, Alta Regional Center Representatives arrived to the facility to assist residents in care relocate to another placement.

At 9:00 PM, all residents were relocated and there were no residents observed to be in care.

An exit interview was held, and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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 10/23/2023 09:01 PM - It Cannot Be Edited


Created By: Christina Valerio On 10/23/2023 at 08:35 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: DOUG & DEBBIE MONDAY'S CARE HOME #2
FACILITY NUMBER: 347001671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2023
Section Cited
CCR
80010(a)

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80010 Limitations on Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation. This requirement was not met as evidenced by:
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Licensee stated they could not create a POC
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Based on observation, the licensee did not ensure all residents were ambulatory. During the walk-through, there was a resident observed to be non-ambulatory, which poses an immediate health and safety risk to residents in care.
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Type A
10/24/2023
Section Cited
HSC1533(a)

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ยง1533 Inspection by department(a) any duly authorized officer, employee, or agent of the State Department of Social Services may...enter and inspect any place...This requirement was not met as evidenced by:
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Licensee stated they could not create a POC
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Based on observation and interviews, the licensee did not allow CCL access to the staff living quarters, which poses an immediate health, safety, and personal rights risk to residents in care.
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Civil Penalities are being assessed due to a repeat violation.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


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Document Has Been Signed on 10/23/2023 09:01 PM - It Cannot Be Edited


Created By: Christina Valerio On 10/23/2023 at 08:43 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: DOUG & DEBBIE MONDAY'S CARE HOME #2
FACILITY NUMBER: 347001671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee stated they could not create a POC
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Based on observations, the licensee did not ensure to maintain the entire home in a clean, safe, sanitary, and good condition, which poses an immediate health and safety risk to 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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
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