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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700264
Report Date: 11/14/2024
Date Signed: 11/27/2024 11:58:49 AM

Document Has Been Signed on 11/27/2024 11:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JEWELL HOME CAREFACILITY NUMBER:
392700264
ADMINISTRATOR/
DIRECTOR:		RALH, MONICAFACILITY TYPE:
740
ADDRESS:1141 S. VAN BUREN STREETTELEPHONE:
(209) 323-4972
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Nordia Heywood and Monica PlowdenTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 11/14/2024 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Nordia Heywood, who was briefly interviewed at this time.
This LPA requested that she go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 6 residents.
It was learned that there were (3) residents under the care of hospice at this time. This facility is approved to be able to accept and retain up to (4) residents under hospice care at any given time.
This LPA requested to review the facility resident files at this time.
A review of (6) facility resident files was conducted and noted on the following LIC 858.
A brief tour of the facility was conducted as well.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

The following civil penalty was assessed and levied in the amount of $500 on the following LIC 421BG.

The following civil penalty was assessed and levied in the amount of $500 on the following LIC 421IM.

Appeal rights were printed and a copy was left with the facility designated representative at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/27/2024 11:58 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/14/2024 at 03:58 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: JEWELL HOME CARE
FACILITY NUMBER: 392700264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2024
Section Cited

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Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or:
This facility was found to be deficient as
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evidenced by the allowance of an individual to be present and employed at this facility prior to obtaining the required criminal clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.
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Type A
11/15/2024
Section Cited

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the
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licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons
This facility was found to be deficient as evidenced by the allowance of facility residents deemed to be Bedridden to be present receiving care and supervision without the proper issuance of a bedridden fire clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.
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deemed as Bedridden.
A statement of correction, along with all required forms and documents for Bedridden Care, will be completed and submitted into CCL by the due date.
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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2024 11:58 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/14/2024 at 04:56 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: JEWELL HOME CARE
FACILITY NUMBER: 392700264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2024
Section Cited

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Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This facility was found to be deficient as
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based on a records review conducted, 1 out of 6 residents, was found to be diagnosed with dementia and did not have an updated medical assessment on file. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.
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completed and submitted into CCL by the 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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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