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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390311376
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:19:44 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/27/2022 12:19 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:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
390311376
ADMINISTRATOR:RICK A. REEDFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE ROADTELEPHONE:
(209) 931-4206
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 15CENSUS: DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cecelia NunezTIME COMPLETED:
12:30 PM
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On 10/27/22 at 9:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with facility supervisor Cecelia Nunez and explained the purpose of today's visit.

The facility consists of 2 separate single story structures. There are 8 residents in one physical plant and 4 residents in the other. LPA Jensen toured the facility including but not limited to living room, dining room, kitchen, bathrooms, bedrooms, laundry room and grounds. The facility was observed to be adequately lit and furnished and odor free. The front entrance carpet leading in to the living room and the hallway of the larger building was observed to be stained in several areas. The single occupancy resident bedroom adjacent to the kitchen was missing a door and as a result remains open to the kitchen and lacks privacy.

LPA Jensen observed in excess of two days supply of perishable food and a 7 day supply of non-perishable food. Staff was preparing beef stew for lunch and apple pie. Knives and sharp objects were observed to be in a locked cabinet and inaccessible to residents in care. Medications were observed to be locked and inaccessible to residents in care. Cleaning supplies and toxins were observed to be locked and inaccessible to residents in care. The first aid kit was observed to be complete. The fire extinguisher was last serviced in June of 2022 and is in compliance. The fire alarm was observed to be in working order. The carbon monoxide detector was tested and observed to be in working order. The water temperature was measured at 105 degrees which falls within the required regulatory range of 105-120 degrees. The thermostat was set at 72 degrees for the comfort of the residents which falls within the required regulatory range of 68-85 degrees. Various activities were observed to be available for the residents to participate in.

3 resident files were reviewed and LPA Jensen observed 3 of 3 resident files were complete.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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: CHEROKEE RETIREMENT HOME
FACILITY NUMBER: 390311376
VISIT DATE: 10/27/2022
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The grounds were observed to be maintained and contained adequate outdoor furnishings for the residents use. There is a chicken coop and chickens on the property. There are no bodies of water on the property.

LPA Jensen is requesting the following documents be emailed to maja.jensen@dss.ca.gov by 11/3/22:

Current month's lease agreement
Proof of Liability Insurance
LIC 500

Deficiencies are being cited today from the California Code of Regulations, Title 22, Division 6. Civil penalties are being issued for repeat violations.

An exit interview was conducted and a copy of this report along with appeal rights was given to facility supervisor Cecelia Nunez.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
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Document Has Been Signed on 10/27/2022 12:19 PM - It Cannot Be Edited


Created By: Maja Jensen On 10/27/2022 at 12:03 PM
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: CHEROKEE RETIREMENT HOME
FACILITY NUMBER: 390311376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by:
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Based on LPA's observation of multiple carpet stains in the main building in the front entrance, living room and hallway. This poses a potential health, safety and personal rights risk to residents in care.
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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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


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