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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700256
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:55:33 PM

Document Has Been Signed on 11/05/2024 03:55 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:
11/05/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Lourdes FernandezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11-5-24 at 2:30pm, the Regional Office conducted an informal meeting with Licensee to discuss recent citations issued and additional concerns. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Licensee Lourdes Fernandez, and Regional Center Representative Chris Pillsbury. Topics in this meeting included: (1) Personal Rights, and (2) Administrator Qualifications and Duties

LPA Bilger and LPM King discussed with licensee the following citations and the associated plans of correction going forward:

On 10/8/24, Licensee was cited by the Department based on the investigation outcome from complaint #27-AS-20240830150730. The following citations were issued:

Type B – 80072(a)(2) Personal Rights due to resident1 (R1) not accommodating R1 after R1 chose not to attend his day program.

Type B – 80072(a)(1) Personal Rights due to R1 being told to attend a day program despite his wish to remain home.

Type B – 80064(a)(2) Administrator-Qualifications and Duties due to residents taken to a private residence for activities which was not approved by regional center or part of facility’s program design resulting in potential safety hazards. {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 392700256
VISIT DATE: 11/05/2024
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During today’s meeting, Licensee agreed to the following: (1) Administrator on duty at least 40 hours per week, (2) Continue to provide staff availability as necessary for residents who wish to remain at home in lieu of attending day program or other activities. Licensee has updated her staffing plan to include adequate coverage.

The department is requesting the following:

1. Licensee has agreed to Technical Support Program (TSP).

2. Updated LIC 602 for resident1 (R1)

3. Updated Individualized Program Plan (IPP) for R1

The Department shall conduct quarterly visits to ensure compliance with the above and all other Title 22 requirements. LPM and LPA notified Administrator that future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and a non-compliance conference to discuss further potential administrative action.

An exit interview was conducted with Licensee and a copy of the report was provided to Licensee

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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