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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 06/20/2023
Date Signed: 06/20/2023 09:06:19 PM


Document Has Been Signed on 06/20/2023 09:06 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:ARLYN'S GUEST HOMEFACILITY NUMBER:
392700049
ADMINISTRATOR:DE LA CRUZ, ARLYN MFACILITY TYPE:
740
ADDRESS:1633 S STOCKTON STREETTELEPHONE:
(209) 392-7049
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:30 PM
MET WITH:Bella Ramos, Lolita Mata, Rose Marie SalvadoTIME COMPLETED:
09:00 PM
NARRATIVE
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LPM Liza King arrived at the facility and met with caregiver (CG) Bella Ramos who is a livein caregiver. The licenssee has been out of the country since the beginning of May. This CG reports that there normal schedule is 4:30 pm to 6am and they work alone during this time period 7 days a week for the past few weeks. CG has been employed for about a month. A check of Guardian shows CG is fingerprint cleared but not associated to the facility. 2 additional CGs arrived at the facility at 7:20 and are fingerprint cleared and associated.
A tour of the facility revealed there are 6 residents whom reside at the facility one of which was sent to the ER earlier in the day. 2 residents require assistance w transfers, several residents appear to be confused, one resident is spanish speaking. CG has no access to personnel files or resident files, in the event of an emergency the CG would contact the licensees husband for assistance. The CG has no access to responsible parties numbers.
A facility sketch was not reviewed or present, staff bedroom was observed to be unlocked with medications present (right side of hall door 2), this door cannot be locked, there is no room for the medications to be locked with resident medications and no other locked area per LPM observations and reported by CGs. Area undersink lock broken and all chemicals accessible. Garage door is unlocked chemicals accessible in unlocked cabinets, some locks are broken others are not but all are unlocked. CG does not have key.
The last door right side of hall labeled "office" unlocked and used as a storage area, no toxins observed, fall hazard present - room has plastic bags and boxes piled up.
Kitchen was observed to be clean and resident medications were locked in cabinet. Refrigerator had a lock which was removed during visit.

The following citations were issued per Title 22 regulations. The RO reserves the right to return at a later date to issue additional citations based on the information provided above incl the absense of the Admin / Licensee from the country without notification to the department. The report was reviewed with CG 1, 2 and 3. The report and appeals rights will be provided via email on 6/21/2023
A LIC500 shall be submitted to the department by end of day 06/22/23.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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 06/20/2023 09:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2023
Section Cited
CCR
87309(a)

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Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This regulations was not met as evidenced by:
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The licensee will provide proof of locks repaired or relpaced on areas that store medications and chemicals to Albert.Johnson@dss.ca.gov.
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lpm observed medications that were accessible in the staff room, cleaning supplies were unlocked under the sink and in unlocked cabinets in the unlocked garage
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Type A
06/22/2023
Section Cited
CCR87705(C)(4)(a)

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Care of Persons with Dementia (A) In addition to requirements a facility with fewer than 16 residents shall have at least one night staff person awake and on duty ...
This regulation was not met as evidenced by:
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The licessee will submit a Plan of correction by 06/22/23 to Albert.Johnson@dss.ca.gov.
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According to staff interview there is one CG present in the facilily from 430 pm to 6am whom sleeps during sleeping hours.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/20/2023 09:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
HSC
87468.1(a)(3)

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Personal Rights: ..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
.(3) To be free from...interfering with daily living functions such as eating, sleeping, or elimination.
This was not met as evidenced by:
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The lock was removed during the visit. The licensee will provide a statement to the LPA Albert.Johnson@dss.ca.gov that this regulation has been read, understood by themself and the staff.
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The LPM observed a chain and lock on the refridgerator.
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Type B
06/22/2023
Section Cited
CCR87411(g)(2)

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Personnel Requirements: (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This was not met as evidenced by:
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The licensee will submit to CCL Albert.Johnson@dss.ca.gov a transfer request on 06/22/23.
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LPM reviewed the facility roster at time of visit and CG1 had a criminal record clearance, however the staff was not associated to the facility and a transfer request had not been submitted.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3