<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700178
Report Date: 08/24/2023
Date Signed: 08/25/2023 08:44:05 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/25/2023 08:44 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: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: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:DeloresTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 to have piles of unused washing machines, boxes, other debris around the house and in to the front yard. LPA observed sufficient furniture and lighting throughout the facility. The main kitchen area is unkempt, expired food and counters full of old food etc...

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 conducted a fire drill this year (3/2023).

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. During the file review for residents LPA observed 4 of 4 service plans outdated. 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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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 3


Document Has Been Signed on 08/25/2023 08:44 AM - 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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
Buildings and Grounds
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.

This facility was deficient as evidenced by:
1
2
3
4
5
6
7
The Licensee will have the facility areas cleaned and debris removed that is not in use.
8
9
10
11
12
13
14
A tour of the facility and space intended for resident use was had unused washing machines, boxes, other debris around the facility which prevented facility residents from going outside to enjoy this space.
8
9
10
11
12
13
14
 A statement of correction, along with photos of the areas and backyard with the debris cleaned up, will be completed and submitted into CCL by the due date of 9/08/2023.
Type B
09/08/2023
Section Cited
CCR80076(a)(1)

1
2
3
4
5
6
7
Food Service. Foods shall be selected, stored, prepared and served in a safe and healthful manner.
LPA observed in the main kitchen area expired food and counters full of old food etc...
1
2
3
4
5
6
7
The Licensee will have the kitchen area cleaned and all old food thrown away.
8
9
10
11
12
13
14
8
9
10
11
12
13
14
 A statement of correction, along with photos of the kitchen cleaned up, will be completed and submitted into CCL by the due date of 9/08/2023.
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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/25/2023 08:44 AM - 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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
80068.2(1)

1
2
3
4
5
6
7
80068.2 (1) The needs appraisal or IPP is not more than one year old.
This requirement is not met as evidenced by: Based on record review, the facility failed to maintain a current service plan for all residents. This posed a potential health and safety risk to resident’s in care.
1
2
3
4
5
6
7
Administrator will complete up to date copies of client's service plans and submit to CCL by 9/8/23. Administrator will to submit a letter to CCL stating regulation 80068.2 has been reviewed by facility Administrator.
8
9
10
11
12
13
14
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3