390305586-5-20-2021-27-AS-MBIR-C37S85-20210520133834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390305586
Report Date: 05/20/2021
Date Signed: 05/20/2021 03:00:25 PM

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:	TENDER LOVING CARE GUEST HOME		FACILITY NUMBER:	390305586
ADMINISTRATOR:	ESTHER JOHNSON		FACILITY TYPE:	740
ADDRESS:	2829-2831 PIXIE DR.		TELEPHONE:	(209) 943-7558
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95203
CAPACITY:	14	CENSUS: 5	DATE:	05/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Kashan Bell		TIME COMPLETED:	01:38 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Bilger arrived to conduct an unannounced Annual inspection on this date. LPA met with Kashan Bell, Administrator and was informed of the purpose of the visit. Administrator was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. Facility is licensed for 14 beds with a fire clearance for 6 ambulatory, 8 non-ambulatory, 0 hospice, and 0 bedridden residents. Current census is 5. Administrator certificate is current and expires on 8/18/22. 2 staff charts were reviewed. All necessary components were present and updated including required training. resident charts were reviewed. All necessary components were present and updated including admission agreement. LPAs toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures. Smoke alarms and carbon monoxide detectors were tested and were operable. LPA toured resident rooms which contained all appropriate furnishings and accommodations. LPA also inspected the living room and family room areas. 7 days of non-perishable, and 2 days of perishable food items. Staff accommodations are located in the hallway area (separate room). Fire extinguisher was charged and last serviced in March 2020. Sharp objects and toxins were inaccessible to residents in care. All staff are fingerprint cleared and associated to work in the facility at this time. LPA observed adequate amount of linens available for

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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: TENDER LOVING CARE GUEST HOME	FACILITY NUMBER: 390305586
	VISIT DATE: 05/20/2021

NARRATIVE

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residents. Medications were locked and secured. Facility temperature measured at 74 degrees F. Hot water temperature measured at 105.2 degrees in kitchen area and 108.6 degrees in bathroom. First aid kit was accessible and stocked appropriately.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, LIC 610E were requested to be submitted to Licensing within 30 days.

As a result of this inspection, deficiencies were cited per Title 22, Division 8{6}, and Health and Safety Code

Exit interview was conducted with Administrator and a copy of report and appeal rights were given at the conclusion of the visit.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: TENDER LOVING CARE GUEST HOME	FACILITY NUMBER: 390305586
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)

Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee was unable to furnish a current copy of the COVID-19 Mitigation Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2021
	Plan of Correction
1 2 3 4	Licensee will work with Northstar for assistance in creating the COVID-19 Mitigation Plan and provide a mitigation plan to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

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