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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700074
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:41:03 PM

Document Has Been Signed on 04/12/2022 04:41 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:WALTERS RESIDENTIAL HOME CARE 2FACILITY NUMBER:
392700074
ADMINISTRATOR:WALTERS, MOSES SRFACILITY TYPE:
735
ADDRESS:4717 WHITE FORGE DRIVETELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tanneh Koayen, Facility ManagerTIME COMPLETED:
12:00 PM
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On 04/12/22 at 9:00 am, Licensing Program Analysts (LPAs) T. White and LPAs Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPAs met with Administrator, Moses Walters and Tanneh Koayen. LPAs explained the purpose of today’s inspection. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on May 11, 2021. LPAs observed completed mitigation plan on file. First aid kit observed to be complete. Fire drill was last conducted on 03/27/2022. LPAs reviewed three (3) client files and three (3) staff record files.

LPAs observed the following deficiencies:
- Based on documentation, facility is licensed to serve 6 ambulatory clients. LPAs observed Client #3 (C3) using a walker throughout the facility.

Report continues on 809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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 04/12/2022 04:41 PM - It Cannot Be Edited


Created By: Treana White On 04/12/2022 at 11:20 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: WALTERS RESIDENTIAL HOME CARE 2
FACILITY NUMBER: 392700074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory...
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in 80010(a). LPAs observed C3 using a walker throughout the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Facility Manager agreed to complete a 30 day eviction, due to the facility being unable to meet the needs of C3. Facility Manager agreed to notify the Fire Department and Follow up with Valley Mountain Regional Center. Facility Manager will submit proof to LPA by POC 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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


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: WALTERS RESIDENTIAL HOME CARE 2
FACILITY NUMBER: 392700074
VISIT DATE: 04/12/2022
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The following forms to be updated and submitted to CCLD by 04/22/2022:
LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan

The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Facility Manager. Appeal rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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