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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700173
Report Date: 08/02/2022
Date Signed: 08/02/2022 11:59:34 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/02/2022 11:59 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:PEOPLE'S CARE WILLORAFACILITY NUMBER:
392700173
ADMINISTRATOR:SIMON, ARNEATHAFACILITY TYPE:
735
ADDRESS:949 WILLORA RDTELEPHONE:
(209) 957-3662
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 5CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Arneatha SimonTIME COMPLETED:
12:00 PM
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On 8/2/22 at approximately 9:00am Licensing Program Analysts (LPAs) Maja Jensen and Ruth Wallace arrived at facility unannounced to conduct a required 1 year annual visit. LPAs met with Administrator Arneatha Simon and explained the purpose of today's visit. Administrator Simon holds a current Administrator's certificate # 6047146735 that is valid through 3/4/24.

The facility is a single story structure with a front yard surrounded by a wrought iron gate. The front yard was landscaped and free of obstruction with a ramp leading to a single designated entry point. LPAs were temperature screened and directed to a hand washing station equipped with signage and paper towels. The current census is 5 . 2 of 5 residents are non-ambulatory which is within the facility's retention limits. LPAs toured the facility including but not limited to kitchen, bathrooms, bedrooms, dining room, common area, laundry room, garage. The facility was sanitary and free of odor with adequate lighting. The facility also had emergency lighting throughout the halls and flashlights available. Signs were posted for personal rights, employee rights, "See something Say something" and COVID precautions. An activity schedule and menu was posted in a prominent area easily viewable by the residents. Residents have an individual outing of their choice one day a week and a group outing one day a week. LPAs Jensen and Wallace observed an emergency food and water supply as well as in excess of 30 days of PPE on hand. There are three first kits available complete with but not limited to manuals, scissors, tweezers, thermometer and various wound dressings.

The fire extinguisher was last serviced in May of 2022 and is in compliance. The carbon monoxide detector and fire alarms were tested and determined to be in good repair. The Emergency Disaster Plan (LIC 610D) was prominently posted and in compliance. There are 2 cordless phones available for client use and a computer with internet access available in the common area.

Continued on LIC 809C.....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: PEOPLE'S CARE WILLORA
FACILITY NUMBER: 392700173
VISIT DATE: 08/02/2022
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The bedrooms were observed to have clean linens and contained all required furniture including dressers, a chair and adequate lighting. The dining room was furnished with a large table and adequate seating for 5 residents. The bathrooms were observed to be clean and in good repair. The bathrooms had paper towel dispensers and were free of hazardous objects or toxins.

The kitchen was observed to be sanitary and with fresh fruit and snacks readily available for residents. There was in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. A menu was posted and was observed to be adhered to. Knives were observed to be locked and inaccessible to residents. Toxins were observed to be locked and inaccessible to residents. Medication was observed to be locked, organized and inaccessible to residents.

In addition to the Administrator, three staff members were working at the facility at the time of inspection. 3 of 3 staff members were observed to have criminal clearance and were associated to the facility. 3 staff files were reviewed and contained all required elements.

The facility maintains a transport van and the registration and insurance were reviewed and determined to be in compliance.

An updated LIC 500 was requested and provided to the LPA for the master file.

The facility was found to be in substantial compliance with California Code of Regulations (CCR), Title 22 therefore no deficiencies were cited as a result of today's visit. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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