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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390302236
Report Date: 04/05/2022
Date Signed: 04/05/2022 04:31:48 PM

Document Has Been Signed on 04/05/2022 04:31 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:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ricky Huber, AdministratorTIME COMPLETED:
11:50 AM
NARRATIVE
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On 04/05/2022 at 9:30 am, Licensing Program Analysts ( LPAs) T. White and R. Campbell arrived unannounced to conduct a Required 1-year Annual inspection. LPAs met with Administrator, Ricky Huber, and explained the purpose of today’s inspection. Administrator Certificate #6025325735 that expires 03/11/2023. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 15 clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. LPAs toured the main house and the annex building. There are no bodies of water observed. LPAs 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 115.3 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 October 08, 2021. Mitigation Plan observed to be complete. First aid kit was observed to be complete. Fire Drill log last conducted 03/17/2022.

LPAs observed the following deficiency:
- LPAs observed the entrance ramp to the facility is a tripping hazard.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency 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: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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 04/05/2022 04:31 PM - It Cannot Be Edited


Created By: Treana White On 04/05/2022 at 11:18 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: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in 80087(c). LPAs observed entrance ramp is a tripping hazard , which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Administrator agreed to repair facility ramp and 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: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
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