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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 06/05/2023
Date Signed: 06/05/2023 11:47:58 AM


Document Has Been Signed on 06/05/2023 11:47 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PLYMOUTH SQUAREFACILITY NUMBER:
390300536
ADMINISTRATOR:TYAH PETERSONFACILITY TYPE:
740
ADDRESS:1319 N MADISON STREETTELEPHONE:
(209) 466-4341
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:32CENSUS: 4DATE:
06/05/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Ramona PellTIME COMPLETED:
11:45 AM
NARRATIVE
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The following deficiencies, initially cited during a visit on 02/23/2023 and 03/01/2023, have been cleared:

Section Cited: 80088(e)(1)Date Due: 02/23/2023
Plan of Correction:
Facility will lower the thermostat and agrees to test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 days hot water temperature to LPA.		Corrections:
Cleared By Visit		Clearance Date:
06/05/2023
Section Cited: 87203Date Due: 03/02/2023
Plan of Correction:
The facility will have the sprinkler system serviced or have the sticker updated to reflect current compliance with the Fire Marshal sticker C16-488359 by POC dated 3/2/2023		Corrections:
Cleared By Visit		Clearance Date:
06/05/2023

During the visit LPA Johnson was made aware that the facility is without a qualified RCFE Administrator. The facility will provide the department with a qualified Administrator by 6/06/2023. The Licensee will also ensure that:

Continued on 809 C


SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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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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: 06/05/2023
NARRATIVE
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1. Administrator will be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. The Administrator will be on site 20 hours/wk. during business hour 9-5 PM Send LIC 500 to CCL by 6/06/2023.

2. Licensee will designate substitute when the administrator is absent from the facility who meets the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and administration of the facility in compliance with regulation. Send LIC 308 to CCL by 6/06/2023.

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 emailed 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: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2023 11:47 AM - It Cannot Be Edited

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: 06/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
CCR
87405(a)

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87405(a) Administrator- Qualifications and Duties: (All Facilities shall have a qualified and currently certified administrator).
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Licensee will submit to LPA an updated LIC500 and LIC200 (with Administrator phone number) with an employee or person who has a current administrator certificate and who
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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 6/6/23

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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: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
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