392700410-9-2-2025-27-AS-NWPN-DL5RTV-20250902131858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700410
Report Date: 08/20/2025
Date Signed: 09/02/2025 01:19:58 PM

Document Has Been Signed on 09/02/2025 01:19 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:	A.J GUEST HOME		FACILITY NUMBER:	392700410
ADMINISTRATOR/ DIRECTOR:	SOARES, CONCEPCION B		FACILITY TYPE:	735
ADDRESS:	1854 ERICKSON CIR		TELEPHONE:	(209) 943-1381
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 4		CENSUS: 4	DATE:	08/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Concepcion Soares		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced on 8/20 at 9:15am to the facility to conduct a annual inspection, the LPA Met with the licensee/administrator Concepcion Soares. A.J Guest Home is a 5 bedroom facility for level 2 adults aged 18 to 59, with a current census of 4 and no residents with restricted conditions. A physical plant inspection was conducted including but not limited to the client bed rooms, client bathrooms, the kitchen, common areas, storage areas, exterior and evacuation routes. traffic areas are well lit. The client bedrooms have the required funiture and funishings. The bathroom hardware is in good repair, LPA asked the water temperature to come up, second measuring at 105.3*F. The kitchen has adequate lockable storage for sharps and medications, Toxics are stored in locked laundry room. The LPA looked at MARs and Medicaitons for 2 clients at random, they are in agreement with kind and quantity. 2-days perishabile and 7 days nonperishable food exists. LPA pointed out an expired can(1 campbells soup), asked all the food to be inventoried, anything dented or expired to be removed from the facility. The licensee agreed to inventory and remove offensive items. The exterior has some malodors and flies, LPA theres some catlitter that needs to be changed and some dog poops that need to be removed, Licensee agrees to keep the exterior area clean and ready for outdoor activies for the clients. There is a body of water, a pool. It is kept locked, LPA was told nobody uses it and it appears unused, still should be maintained for cleanliness. The evacuation route is obstructed with two eye bolts and a post, and the gate drags against the ground, LPA asked that the bottom of the gate gate be maintained to be able to swing freely and not be obstructed by these items. LPA suggested a self closing latch and a camera in use sign be applied instead. Continued on C Page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: A.J GUEST HOME	FACILITY NUMBER: 392700410
	VISIT DATE: 08/20/2025

NARRATIVE

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Facility posters are of the correct size and present excepting the right of resident councils(Pub464), the licensee will print out and post it. The fire extinguisher is dated 4/14/25. Smoke and CO detectors are functional.

Administrator documents are up to date and present including but not limited to: certificate, Hiv, surety bond, liability insurance, control of the property( via rental agreement), first aid/cpr, continuing and initial trainings.

4 of 4 client files were reviewed and found with approprited documentation including but not limited to: IPPs, 602s, preappraisals for health and mental health, and signed admission agreements with house rules and personal rights amendums.

0 staff files were reviewed, there were at some point 2 other staff, 1 who quit and one who went on pregancy leave and never came back almost a year ago. The Licensee is the only care and supervision availible to the residents, they live here with them. The LPA looked into the facilities need for supervision, and the folks interviewed are practically fully independant, two are not on any perscribed medications, only one requires minor prompting to take care of thier basic needs(cleaning thier room). LPA expressed concern about the ability of the Licensee to provide care and supervision if they were somehow incapacitated or otherwise unavailible, and the facility's need to have someone availibile for a staff to respond to an inspection authority of a serious complaint or other ugent matter within 30 minutes. The Licensee has a son and a neice, previous workers to this facility, who are living nearby and possibly willing to become an on-call staff able to respond within 30 minutes, as well as reaching out to 1 or 2 more people she knows in the community care industry to fill this role. The Licensee is also considering hiring a staff. LPA is asking the Licensee to send in a new LIC 500 and LIC 308 immediately or within 24 hours, detailing those people, their roles, and their hours.

0 staff were interviewed, as reasoned above.

2 clients were interviewed.

An exit interview was conducted, a copy of the report was read and given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC809 (FAS) - (06/04)

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