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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 03/01/2023
Date Signed: 03/01/2023 04:06:37 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/01/2023 04:06 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:PLYMOUTH SQUAREFACILITY NUMBER:
390300536
ADMINISTRATOR:TYAH PETERSONFACILITY TYPE:
740
ADDRESS:1319 N MADISON STREETTELEPHONE:
(209) 466-4341
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:32CENSUS: 6DATE:
03/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:T PetersonTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Johnson arrived at facility to conduct a Case Management visit to follow-up on the requested information from the annual survey on 2/23/2023.

During continued survey LPA observed that the water temperature is still measuring at 127.5 in the resident's room 314 and the fire marshal sticker is not updated as requested. The facility had paper work from the service provider regarding the original visit, however, the servicing agency has not updated the sticker for an unknown reason.

As a result, the facility is out of compliance with both standards and the citation for the water temperature will not be cleared. The sticker for the sprinkler system is out of compliance for the annual inspection or service (The sticker is dated 6/2021 due annually). Photo taken.

Deficiencies cited and civil penalties assessed.

Failure to correct cited deficiencies by due dates will incur daily civil penalty assessments until the deficiencies are corrected.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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 03/01/2023 04:06 PM - 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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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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
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This requirement is not met as evidenced by: Based on observation the sticker for the sprinkler is system is out of compliance for the annual inspection or service (The sticker is dated 6/2021 due annually). this poses a potential health and safety risk to the residents in care
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Civil penalty assessed

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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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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