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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390305107
Report Date: 03/08/2022
Date Signed: 03/09/2022 07:08:43 AM

Document Has Been Signed on 03/09/2022 07:08 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:SOLIDUM GUEST HOME 2FACILITY NUMBER:
390305107
ADMINISTRATOR:SOLIDUM NORMAFACILITY TYPE:
735
ADDRESS:3115 APPLING CIRCLETELEPHONE:
(209) 952-4276
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lynn Caoli, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
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LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by care staff who informed Administrator Lynn Caoli of the LPA's visit and Ms. Caoli arrived during the visit. LPA explained the purpose of the visit and staff accompanied LPA on the facility inspection.

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. There are 3 client bedrooms and 2 client bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing and other signage noted. Medications noted to be locked to residents in care. . LPA also conducted the infection control domain tool.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: SOLIDUM GUEST HOME 2
FACILITY NUMBER: 390305107
VISIT DATE: 03/08/2022
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were checked May 2021 and are in compliance. Facility has an emergency food and water supply in a separate storage area in kitchen. All staff on-site have current fingerprint clearances. Administrator Certificate #6001906735 for Lynn Caoli. Expires 12/4/2022

LPA requested the following documents to be updated: Copy of current lease agreement and copy of surety bond, LIC 500 and LIC 309 need updating and due to Licensing within 30 days.

Per California Code of Regulations, Title 22 no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Caoli.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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Document Has Been Signed on 03/09/2022 07:08 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 03/08/2022 at 10:36 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: SOLIDUM GUEST HOME 2
FACILITY NUMBER: 390305107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following:

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 as LPA observed large amount of clutter in the back yard. Things such as yard equipment, exercise equipment etc which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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FAcility will clean and organize the backyard area and send proof of complinace by POC due date of 4/8/22.
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:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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