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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390305107
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:48:42 PM

Document Has Been Signed on 09/27/2024 12:48 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SOLIDUM GUEST HOME 2FACILITY NUMBER:
390305107
ADMINISTRATOR/
DIRECTOR:		SOLIDUM NORMAFACILITY TYPE:
735
ADDRESS:3115 APPLING CIRCLETELEPHONE:
(209) 952-4276
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
09/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Lynn CoaliTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 9-27-24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit regarding incidents which occurred on 9/25/24. LPA met with administrator Lynn Caoli and explained the purpose of the visit. LPA reviewed incident report dated 9-26-24 and facility file documentation for resident (R1). LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed administrator.

On 9-26-24, facility reported that R1 passed way. on 9/25/24, R1 was found at the facility unresponsive and was not waking up when prompted vitals were checked and no pulse was found so CPR was started and 911 was called. R1 was pronounced deceased at the facility. on 9/24/24 R1 was wake and lucid when licensee visited the night before. Facility provided R1's 602 (physician's report), IPP and Functional assessment, care notes, Diabetic levels and admissions agreement.

LPA conducted facility tour with administrator. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Fire extinguisher was full charged and dated 9-15-23. Room temperature was 71*F. Smoke alarms and carbon detectors are functioning properly. Current census is 3. No obstructions to fire exits noted during today's tour. As a result of today's case management visit, no deficiencies are being cited under Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report was given.

This matter is still under investigation.

Licensee will obtain death certificate from family when available and email to LPA Lewis.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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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