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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700178
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:46:20 PM

Document Has Been Signed on 07/08/2021 04:46 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:DULAY GUEST HOME 4FACILITY NUMBER:
392700178
ADMINISTRATOR:MENDOZA, LOVEMINDAFACILITY TYPE:
740
ADDRESS:653 CHICAGO AVETELEPHONE:
(209) 482-8230
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
07/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Luvi Mendoza TIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Albert Johnson arrived at the care home today and met with licensee, Luvi Mendoza to conduct a case management visit. The purpose of the visit is to follow up on a report from the department's sister agency regarding bed bugs.

LPA informed licensee that the visit was to follow-up on the plan to eradicate the bed bugs from the facility, also, the licensee needs to follow-up on R1's home health for the care of R1's legs. Please provide the department with a physician's order and home health plan for treatment of R1's legs by 7/12/2021.

Deficiencies are being cited today on the attached 809D page. Exit interview conducted, appeal rights given and a copy of this report left at the conclusion of this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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 07/08/2021 04:46 PM - It Cannot Be Edited


Created By: Albert Johnson On 07/08/2021 at 01:38 PM
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: DULAY GUEST HOME 4
FACILITY NUMBER: 392700178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe,
sanitary and in good repair at all times for the
safety and well-being of clients, employees and
visitors. (1) The licensee shall take
measures to keep the facility free of flies and
other insects.
This requirement is not met as evidenced by:
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Based on interviews and evidence received. bed bugs were reported in the facility by another agency.
Facility has been privately treated for bedbugs by Licensee. This poses a potential
health risk to the persons in care.
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Administrator will send copy of invoice from the
exterminator company to show that the facility
inspection was completed via email to LPA no
later than 07/15/2021

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
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