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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317219
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:51:44 PM

Document Has Been Signed on 03/15/2024 03:51 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:LOS FELIS CARE HOMEFACILITY NUMBER:
390317219
ADMINISTRATOR:STA TERESA, INGRID PILFACILITY TYPE:
735
ADDRESS:813 W. LOS FELIS ST.TELEPHONE:
(209) 478-5576
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
03/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Ingrid Sta.TeresaTIME COMPLETED:
04:05 PM
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On 3-15-24 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. The purpose of today's case management visit was to address two previously reported incidents. LPA met with Administrator Ingrid Sta. Teresa and explained the purpose of the visit. LPA reviewed incident reports dated 12-12-23 and 2-20-24. LPA reviewed individualized service plans (IPPs) and physician reports for resident1 (R1) and R2. LPA also conducted brief interview with Administrator, staff1 (S1), and R1. LPA reviewed additional facility file documentation during today's case management and conducted a facility observation
Incident #1: LPA reviewed incident report dated 12-13-23 which states that on 12-12-23 resident3 (R3) was witnessed at day program by day program staff to contain an insect on R3's t-shirt and neck area. The insect was identified by day program staff as a cockroach. After day program notified facility, Licensee initiated pest control services for pest clearance purposes as requested by day program. LPA observed and reviewed service details of pest control company dated 12-13-23 which states treatment performed and the verbiage: "I can confirm there is no roach/pest activity inside/outside of home" as written by service technician. Additionally, LPA observed and reviewed facility regular pest control services prior to and after reported incident. A facility observation conducted did not reveal presence of insects within facility.

Incident #2: LPA reviewed incident report dated 2-20-24 which states that on 2-19-24, R1 disclosed being inappropriately touched by R2 and reported to facility staff. LPA conducted interview with Administrator, S1, and R1. Based on interviews and record review, it was determined that incident was reported to licensing department, Ombudsman, and local law enforcement. It was further determined through interviews that there have been no additional incidents of inappropriate touching between residents since this reported incident and facility is maintaining a safe environment for residents at this time. Additionally, a follow up physican's visit for R1 was initiated by Licensee on 2-28-23 regarding above incident. LPA further reviewed IPPs and physician reports for purposes of determining appropriate intervention for residents in care.
As a result of today's case management, no citations are issued.An exit interview was conducted with Ingrid Sta. Teresa and a copy of this report was provided to Ingrid.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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