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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700412
Report Date: 08/02/2024
Date Signed: 08/02/2024 11:15:49 AM


Document Has Been Signed on 08/02/2024 11:15 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: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:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Randy MorelosTIME COMPLETED:
11:20 AM
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On 08/02/2024 at 10:15 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Randy Morelos and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for four non-ambulatory residents and two ambulatory residents. The facility has a hospice waiver for six. There are currently four residents who reside at this facility.

The LPA Martinez toured the facility with Randy Morelos on 08/02/2024 at 11:00 AM.

The facility has a natural disaster plan, and an infection control plan. The facility has a first aid kit, and has a locked cabinet for medication storage. The facility water temperature measured at 108 degrees, and the facility temperature measured at 75 degrees. The carbon detectors and smoke detectors and fire extinguishers were in good repair. LPA Martinez reviewed four resident files and three staff files, which the files were maintained. LPA Martinez reviewed four medication administration record (MAR), and the four MARs were maintained. The facility bedrooms, bathrooms, common areas, and laundry room were sanitary and furnished. The exterior of the facility is clear of debris and sanitary. The facility has an adequate food supply. Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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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