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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 07/02/2021
Date Signed: 07/02/2021 06:41:25 PM

COMPREHENSIVE INSPECTION
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:PLYMOUTH SQUAREFACILITY NUMBER:
390300536
ADMINISTRATOR:WILLY DE MESAFACILITY TYPE:
740
ADDRESS:1319 N MADISON STREETTELEPHONE:
(209) 466-4341
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:32CENSUS: 13DATE:
07/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cecilia Catbagau and Juanita JonesTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Cecilia Catbagau and Juanita Jones. The facility has not had an Administrator since May of 2021. LPA was able to establish a Designation Of Facility Responsibility (LIC 308), however, they are not an Administrator.

LPA inspected physical plant including but not limited, bedrooms, bathrooms, and dining room area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in/ or around the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 122.9 degrees Fahrenheit in resident's bathroom sink (room 314), which is not within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present.

LPA observed centrally stored medications locked inside the medication cart. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed an incident for R1, antibiotics were ordered and not started until nine days later. LPA reviewed 5 resident files and 4 staff files including past Administrator's file.

Continued
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PLYMOUTH SQUARE
FACILITY NUMBER: 390300536
VISIT DATE: 07/02/2021
NARRATIVE
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 First aid kit was checked and is complete. Fire drill was completed on 6/15/2021.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, deficiencies were observed and cited during this visit. Exit interview held and a report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLYMOUTH SQUARE
FACILITY NUMBER: 390300536
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2021
Section Cited

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Administrator-Qualifications and Duties:All Facilities shall have a qualified and currently certified administrator.
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This requirement was not met as evidenced by facility not having an administrator with current administrator certificate associated to the facility. This poses an immediate health and safety risk to residents in care.
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will act in the administrator capacity until Licensee obtains, hires or contracts with an administrator that is certified with CDSS by POC date 7/3/2021
Type A
07/03/2021
Section Cited

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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LPA tested hot water at 122 degrees F. Licensee did not assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a immediate health and safety risk to resident 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLYMOUTH SQUARE
FACILITY NUMBER: 390300536
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2021
Section Cited

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87465(a)(5)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by staff interview and review of resident records. It was found that resident R1 did
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not started medication ordered by the physician until 9 days after the facility contacted the Physician. This is an immediate risk to residents in care.
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Topics shall include: Medication storing, administering ordered medications, medication documentation, medication destruction and refilling meds. The date of training and training company shall be submitted to CCL by POC date. Once training is completed, proof of completion shall be submitted to CCL.

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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4