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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317879
Report Date: 01/06/2022
Date Signed: 01/10/2022 06:23:26 AM

Document Has Been Signed on 01/10/2022 06:23 AM - 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:TACSION'S GUEST HOMEFACILITY NUMBER:
390317879
ADMINISTRATOR:TACSION, MYRNA L.FACILITY TYPE:
735
ADDRESS:4314 ESTATE DRIVETELEPHONE:
(209) 957-0185
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 5DATE:
01/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Myrna Tacsion, Facility AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual inspection on this date. The Administrator for the facility, Myrna Tacsion was informed of the purpose of the visit, arrived at the home and was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility is Regional Center vendorized home and is vendorized for a 4I level. The facility has 5 clients and 3 bedrooms. All clients were at the home and engaged in virtual day program classes and other activities.

LPAs toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Smoke alarms were tested and were operable. Fire extinguishers were serviced in December 2001. Toxins and medications were locked and inaccessible to clients in care. However, LPA observed Lysol spray in one bathroom and car engine supplies in the garage, both unsecured. Food supply determined to be adequate. Inside and outdoor exits were unlocked and accessible. Water temperature was measured at 117.5 degrees F. Staff and resident file reviewed.

LPA observed the following posted in the facility: COVID requirements, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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Document Has Been Signed on 01/10/2022 06:23 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 01/06/2022 at 10:02 AM
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: TACSION'S GUEST HOME
FACILITY NUMBER: 390317879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 which poses/posed a potential health, safety or personal rights risk to persons in care. Lysol spray was observed in a bathroom and car engine supplies were observed in the garage, both unsecured.
POC Due Date: 02/07/2022
Plan of Correction
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Facility staff secured items during LPA's inspecition facility will provide in-service training to staff within 30 days and send proof of trainng to CCL.
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:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022


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: TACSION'S GUEST HOME
FACILITY NUMBER: 390317879
VISIT DATE: 01/06/2022
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Exit interview held with acting Administrator, one Type B deficiency was issued and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC809 (FAS) - (06/04)
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