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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390302236
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:54:17 PM

Document Has Been Signed on 10/06/2021 04:54 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:HUBER'S GUEST HOMEFACILITY NUMBER:
390302236
ADMINISTRATOR:HUBER, RICKYFACILITY TYPE:
735
ADDRESS:18759 N. CHESTNUT ST.TELEPHONE:
(209) 368-8330
CITY:WOODBRIDGESTATE: CAZIP CODE:
95258
CAPACITY: 15CENSUS: 14DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ricky Huber, AdministratorTIME COMPLETED:
12:35 PM
NARRATIVE
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On 10/06/2021 at 9:50 am, Licensing Program Analyst (LPA) T. White spoke with Administrator, Ricky Huber regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 10:00am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Ricky Huber, and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. LPA toured the main house and the annex building. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 108.9 and 113.4 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on August 27, 2020. Mitigation Plan observed to be complete. First aid kit was observed to be complete.

- LPA observed hedge trimmers and branch cutters on the outside porch accessible to clients in care.
- LPA observed expired fire extinguisher, which dated August 27, 2021.
- LPA observed 2 holes in clients shared bedroom floors. Administrator stated the facility is in the process of upgrading the facility floors.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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: HUBER'S GUEST HOME
FACILITY NUMBER: 390302236
VISIT DATE: 10/06/2021
NARRATIVE
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The following forms to be updated and submitted to CCLD by 10/15/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 04:54 PM - It Cannot Be Edited


Created By: Treana White On 10/06/2021 at 11:36 AM
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: HUBER'S GUEST HOME
FACILITY NUMBER: 390302236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 80087(g). LPA observed unlocked hedge trimmers and branch cutters located on the outside porch which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Administrator removed branch cutters and hedge trimmers and locked it away. Deficiency cleared during inspection.
Request Denied
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 80020(a). LPA observed fire extinguisher expired on August 26, 2020 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Administrator agreed to purchase or service fire extinguisher and submit proof by POC date.

CIVIL PENALTY ASSESSED
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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 04:54 PM - It Cannot Be Edited


Created By: Treana White On 10/06/2021 at 11:36 AM
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: HUBER'S GUEST HOME
FACILITY NUMBER: 390302236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 80087(a). LPA observed 2 holes in clients shared bedroom floors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Administrator stated the facility is in the process of upgrading the floors. Administrator will submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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