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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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 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
Liza KingTELEPHONE: (650) 676-0442
Charlie YangTELEPHONE: (916) 709-6507
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

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: JEWELL HOME CARE
FACILITY NUMBER: 392700264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
Deficient Practice Statement
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POC Due Date: 11/15/2024
Plan of Correction
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This facility representative stated that all facility staff will always be fingerprint cleared and properly associated prior to employment. A statement of correction, along with updated LIC 500, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Liza KingTELEPHONE: (650) 676-0442
Charlie YangTELEPHONE: (916) 709-6507

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

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: JEWELL HOME CARE
FACILITY NUMBER: 392700264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
Deficient Practice Statement
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POC Due Date: 11/15/2024
Plan of Correction
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This facility representative stated that all residents diagnosed with dementia will be reviewed to make sure that all medical assessments have been updated to address any changes in care and supervisory needs. A statement of correction, along with a copy of the updated medical assessment, will be
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Liza KingTELEPHONE: (650) 676-0442
Charlie YangTELEPHONE: (916) 709-6507

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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