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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700256
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:25:54 PM

Document Has Been Signed on 04/12/2022 03:25 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:H AND R HOME CARE FACILITY #2FACILITY NUMBER:
392700256
ADMINISTRATOR:FERNANDEZ, LOURDES CFACILITY TYPE:
735
ADDRESS:928 DEWITT COURTTELEPHONE:
(209) 547-1961
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
04/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Lourdes FernandezTIME COMPLETED:
04:05 PM
NARRATIVE
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On 4-12-22 at 2:12pm, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit for an incident which occurred on 3/18/22. LPA met with Administrator Lourdes Fernandez and explained the purpose of the visit. LPA interviewed Administrator and requested Individualized Program Plan (IPP) for client1 (C1) and Physician's Report for C1. According to incident report received by licensing department on 3/21/22, C1 was admitted to facility on 3-18-22 and residing as a respite stay. On 3-18-22, C1 engaged in an inappropriate behavior which resulted in respite stay to be discontinued.

Based on interview, facility conducted an interview with regional center and C1's responsible person, but did not secure a physician's report prior to accepting C1 into care. C1 was sent back home with responsible person on 3-18-22.

Deficiencies are cited today under Title 22, Division 6, Chapter 1. An exit interview was conducted with Lourdes Fernandez and a copy of this report was given to Lourdes. Appeal Rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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 04/12/2022 03:25 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/12/2022 at 03:08 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: H AND R HOME CARE FACILITY #2
FACILITY NUMBER: 392700256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
80069(b)(1)

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Client Medical Assessment. (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
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Licensee will read regulation 80069(b)(1) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will obtain Individualized Service Plan (IPP) and submit copy to LPA by POC due date.
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This requirement is not met as evidenced by: Based on interview, licensee did not secure a medical assessment for C1 prior to accepting C1 into care on 3-18-22. This poses a potential health and safety risk to clients 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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