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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312365
Report Date: 08/08/2022
Date Signed: 08/08/2022 03:41:16 PM

Document Has Been Signed on 08/08/2022 03:41 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:CARCIDO'S GUEST HOME #3FACILITY NUMBER:
390312365
ADMINISTRATOR:CARCIDO, MEDINAFACILITY TYPE:
735
ADDRESS:9851 NORTHRIDGE WAYTELEPHONE:
(209) 952-8490
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Medina CarcidoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 8-8-22 at 1:28pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Medina Carcido and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed adult residential facility with a current census of 6. Facility has 3 bedrooms and 2 bathrooms for resident use. A separate office/living room is off the entry way. There is a separate laundry room with access which leads to garage access. Dining area is off the kitchen area. LPA observed laundry detergent accessible to clients in care in laundry room and garage. Additionally, LPA observed paint in cans in the garage accessible to clients. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan in place. 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, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and backyard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Seven staffing charts were reviewed. 3 of 7 charts contained expired First aid/CPR certifications.

Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. No obstructions to fire exits noted. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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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: CARCIDO'S GUEST HOME #3
FACILITY NUMBER: 390312365
VISIT DATE: 08/08/2022
NARRATIVE
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked June 17, 2022. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Medina Carcido. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/08/2022 03:41 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/08/2022 at 03:09 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: CARCIDO'S GUEST HOME #3
FACILITY NUMBER: 390312365

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in that LPA observed laundry detergent accessible to clients in laundry room and garage. Additionally, LPA observed paint in cans accessible to clients in garage. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee will conduct staff training on regulation 80087(g) and submit proof of completed training to LPA by POC due date.

Licensee will submit a plan on ensuring how toxins, sharp objects, and other dangerious items will be inaccessible to clients in care. Plan to be submitted to LPA by POC due 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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/08/2022 03:41 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/08/2022 at 03:09 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: CARCIDO'S GUEST HOME #3
FACILITY NUMBER: 390312365

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 7 staffing charts reviewed. Staff1 (S1), S2, and S3 first aid/CPR certifications were expired. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee will ensure completed first aid/CPR certifications for S1, S2, and S3 by POC due date. Licensee to submit proof of completed certifications to LPA by POC due 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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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