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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700256
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:39:02 PM

Document Has Been Signed on 01/29/2025 04:39 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:H AND R HOME CARE FACILITY #2FACILITY NUMBER:
392700256
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, LOURDES CFACILITY TYPE:
735
ADDRESS:928 DEWITT COURTTELEPHONE:
(209) 547-1961
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
01/29/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Melba PicardoTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On 1-29-25 at 3:40pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met lead caregiver Melba Picardo and explained the purpose of the visit. Administrator Lourdes Fernandez was made aware of visit and purpose, and gave permission for lead caregiver to sign in her absence. LPA conducted brief interview with Administrator during today's visit and reviewed facility file documentation including LIC 500, physician's report for resident1 (R1), and individualized program plan (IPP) for R1.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. LPA observed Administrator on duty and an additional staff on duty. Administrator departed prior to completion of this visit. LPA also observed six residents with staff providing needs as appropriate.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished.

Review of LIC 500 revealed Administrator is on duty 33 hours per week instead of the 40 hour per week requirement as set forth by the Department on 11-5-24 during a previous informal meeting. LPA observed physician's report and IPP for R1 have been updated and pending final signature of appropriate parties involved.
As a result of today's visit, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with lead caregiver and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 01/29/2025 04:39 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/29/2025 at 03:56 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: H AND R HOME CARE FACILITY #2
FACILITY NUMBER: 392700256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
CCR
85064(e)

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85064 Administrator Qualifications and Duties. (e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. This requirement is not met as evidenced by:
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Administrator to update staffing schedule and plan to include Administrator coverage of at least 40 hours per week. Updated schedule and plan to be submitted to LPA by POC due date.
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Based on interview and record reivew, Administrator is currently present 33 hours per week instead of the 40 hour per week requirement as set forth by the Department on 11-5-24. This poses a potential health and safety risk to residents in care.
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Administrator will read regulation 85064(e) and submit a signed declaration of understanding to LPA by POC due date.

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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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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