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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700264
Report Date: 12/03/2024
Date Signed: 12/03/2024 03:50:00 PM

Document Has Been Signed on 12/03/2024 03:50 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: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: 5DATE:
12/03/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Monica PlowdenTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Announced Office Informal Meeting was conducted via Teams Meeting by Licensing Program Manager (LPA) Liza King and Licensing Program Analyst (LPA) Charlie Yang who were also joined by the following individuals:

1. Long Term Care Ombudsman Kathryn Thomas
2. Facility Licensee Monica Plowden

The purpose of this meeting was to conduct an Informal Meeting and follow up with the facility Licensee Monica Plowden in regard to some recent events and incidents that have taken place at this facility.

The following issues were discussed and reviewed at this time:

· Fire Clearance
· Reporting Requirements
· Personal Rights
· Staffing
· Medication Policies and Procedures
Liza KingTELEPHONE: (650) 676-0442
Charlie YangTELEPHONE: (916) 709-6507
DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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: JEWELL HOME CARE
FACILITY NUMBER: 392700264
VISIT DATE: 12/03/2024
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The facility Licensee Monica Plowden will complete and submit the following:
  • LIC 500
  • LIC 200
  • Facility Sketch (LIC 999)
  • LIC 308
  • Updated training for all staff (4) in regard to Medications
  • Updated training for all staff (4) in regard to Residents’ Personal Rights
  • Updated training for all staff (4) in regard to Proper Reporting Requirements
  • During the monitoring period, proof of fingerprint clearance will be submitted to the Department prior to hire.
  • During the monitoring period, the facility will maintain a Resident Roster and submit it to the Department monthly.
  • During the monitoring period, all training shall be conducted by an outside provider
This facility Licensee was given until the COB of 12/17/2024 to complete and submit all of the above forms and documents into CCL for review.

In addition, the Licensee agreed that the following will be put into place:
1. The Administrator will be present at least 40 hours a week during the increased monitoring time period. These hours will be reflected on the updated LIC 500 provided to CCL.

A discussion was held about the facility Licensee’s voluntary engagement with Technical Support Program (TSP). Licensee did agree to participate in TSP.

CCL will increase monitoring over the next 12 months to provide oversight and guidance as needed.
The Department provided the following resources:
Technical Support Program
Dementia Care Information and Resources

No citations issued. A copy of the report was reviewed with the Licensee and provided via email.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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