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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700412
Report Date: 11/09/2020
Date Signed: 11/09/2020 03:25:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHIANTI JOY LLCFACILITY NUMBER:
392700412
ADMINISTRATOR:MORELOS, RANDY SFACILITY TYPE:
740
ADDRESS:9152 CHIANTI CIRTELEPHONE:
(209) 242-2006
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
11/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Randy MorelosTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Albert Johnson and Ashley Boothe conducted a health and safety check on this day.

At 1:30pm LPA's and administrator toured the facility and observed the following deficiencies in the facility: expired food stored and cloth towels hanging in restroom.

The facility is practicing face covering while providing care and supervision to residents in care and also used screening per COVID precautionary guidelines.

During file review at 2:10pm, LPA's and administrator observed records for R1 and R2 and R3. R1 states diagnosis of dementia. R2's LIC602 states R2 is diabetic and is not able administer own medications, as well as manage his sliding scale injections. R3 also has a diagnosis that includes dementia. The facility is providing care to these residents outside of the scope of their license. The facility care provider is checking sugar levels and injecting based on these level checks.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Randy. A a copy of this report was provided to Randy via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Randy is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHIANTI JOY LLC
FACILITY NUMBER: 392700412
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited

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87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (5) Diabetes as specified in Section 87628. (8) Injections as specified in Section 87629.
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This requirement is not met as evidenced by: LPA's and administrator interviews and records review of R2's LIC602 and appraisal which states R2 is diabetic and is not able administer own medications, as well as manage his sliding scale injections. The caregiver is providing care to R2 on the restricted health condition. This poses an immediate risk to residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
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