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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700178
Report Date: 07/28/2022
Date Signed: 07/28/2022 05:39:20 PM


Document Has Been Signed on 07/28/2022 05:39 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: 6DATE:
07/28/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:DeloresTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual on this date. LPA met with Delores and explained the purpose of the visit.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 119.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers are current, Smoke detectors and carbon dioxide monitor are operational. The facility has not conducted a fire drill this year.

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. R1 is refusing to take his medication. The facility has notified R1's doctor about the situation. LPA reviewed resident and staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed during this visit.

Exit interview held and a report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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 07/28/2022 05:39 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
CCLD Regional Office, 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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited

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Drills shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
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Based on observation the licensee did not comply with the section cited above in 1569.65(c). LPA observed Administrator was unable to provide a copy of facility fire drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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