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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700173
Report Date: 07/14/2023
Date Signed: 07/14/2023 12:51:23 PM

Document Has Been Signed on 07/14/2023 12:51 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
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:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arneatha SimonTIME COMPLETED:
01:00 PM
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On 7/14/23 at approximately 10:00am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Arneatha Simon and explained the purpose of today's visit. Upon arrival there was no one at the facility. LPA Jensen called the Administrator and the Administrator met the LPA on site. The clients were on outings or in Day Program.

The facility is licensed for a capacity of 5 and of the 5 clients 2 may be non-ambulatory. LPA Jensen toured the facility and grounds. The grounds were maintained and all passages were observed to be free of obstruction. There is outdoor furniture available and shaded areas for the clients to engage in outdoor activities. The interior of the facility was observed to be sanitary and free of odor. The thermostat was at 77 degrees Fahrenheit and falls within the required regulatory range of 68-85 degrees Fahrenheit. LPA observed the facility sketch posted on the wall and verified that the sketch accurately reflects the facility layout and room usage. LPA Jensen also observed signs posted through out the facility easily viewable by resident and visitors alike for Rights of Individuals with Developmental Disabilities, "See Something, Say Something", and the Emergency Disaster Plan. The Emergency Disaster Plan was last updated on 6/20/23 and is in compliance. The fire extinguisher was last serviced in May of 2023 and is in compliance. The carbon monoxide and smoke detectors are in a single combined unit and were determined to be in working order. The facility maintains 1st aid kits that are complete with all necessary elements. There is emergency lighting available throughout. The facility maintains an emergency food and water supply.

LPA Jensen observed adequate lighting and furniture throughout the home. The bedrooms are equipped with a chair, night stand, dresser and reading lights. The mattresses have protective covers added or built in. The facility maintains an adequate supply of linens and hygiene products. Toxins, knives and medications are locked and inaccessible to residents on care. The bathroom temperature was measured at 108.4 degrees and falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility also measures the water temperature daily and keeps a temperature log posted. Continued on LIC 809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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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: 07/14/2023
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Continued from LIC 809...
The kitchen was observed to be sanitary and with all appliances in good working order. The facility maintains in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. Perishable food items that have opened are labeled with the date opened. There was no expired food observed. The facility posts a menu that was verified as being adhered to. When there are changes to the menu it is updated accordingly. LPA Jensen also observed special instructions posted for modified diets as prescribed by a physician.

LPA Jensen reviewed 2 staff files and determined them to be complete with training requirements, criminal background clearance and current 1st certifications. LPA Jensen reviewed 3 of 5 resident files and determined them to be complete and organized. LPA Jensen reviewed the P&I funds and determined the accounting to be accurate.

LPA Jensen interviewed 2 staff members. The 2 staff members were able to appropriately answer all questions asked. LPA Jensen interviewed 1 resident. The resident confirmed that all needs are being met and that they are being treated with dignity. LPA Jensen observed lunch service and verified that clients with modified diets received meals as prescribed by the physician.

LPA Jensen requested the following documents to be emailed by 7/21/23:

Current LIC 500
Current Surety Bond
Current Liability Insurance

The facility was observed to be in substantial compliance. No citations were issued as a result of this inspection. An exit interview was conducted and a copy of this report was handed to Arneatha Simon.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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