392700412-6-16-2023-27-AS-RCAL-CSUSUD-20230616141058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700412
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:11:57 PM

Document Has Been Signed on 06/16/2023 02:11 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	CHIANTI JOY LLC		FACILITY NUMBER:	392700412
ADMINISTRATOR:			FACILITY TYPE:	740
ADDRESS:	9152 CHIANTI CIR		TELEPHONE:	(209) 242-2006
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY:	6	CENSUS: 2	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Randy Morelos, Administrator		TIME COMPLETED:	02:30 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) Renee Campbell and Regional Manager (RM) Stephenie Doub conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Randy Morelos. The administrator currently holds a certificate (#6013638740) that expires on 05/16/2024. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms of which 4 bedrooms can be occupied by up to 6 residents and no bedroom is occupied by staff. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. There were 6 smoke alarms and 1 carbon monoxide alarm that were found to be functioning. Fire extinguishers last inspected on 07/20/2022. Residents’ bathrooms were equipped with grab bars. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. LPA reviewed 2 of 2 resident files. Of the two resident files reviewed, one client did not have a current 602 and neither client has a Needs and Services Plan. There were 3 of 3 staff files that were reviewed. Staff are missing required continuing education requirements. In resident bedrooms, two of two bedrooms had deadbolts on both sides. LPA Campbell observed that the facility had no obstructions in hallways..

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHIANTI JOY LLC	FACILITY NUMBER: 392700412
	VISIT DATE: 06/16/2023

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by: 06/22/2023

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2023 02:11 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHIANTI JOY LLC	FACILITY NUMBER: 392700412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(l)(6)

(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 2 out of 4 bedrooms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Licensee will make the change himself and ensure doors can be unlocked from the inside by poc date and provide pictures sent to renee.campbell@dss.ca.gov.

Type B

Section Cited

CCR

87506(b)

Each resident’s record shall contain at least the following information: ...(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 files for their Needs and Service and 1 ouf of 2 files for their Medical Assessment which poses potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Licensee will provide current 602 and Needs and Services for all clients by POC Date and email it to LPA at renee.campbell@dss.ca.gov. Licensee will contact LPA by POC date when the appointment is set for a medical appointment. The Needs and Services will be completed by POC date as well.

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: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 10 of 11

Document Has Been Signed on 06/16/2023 02:11 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHIANTI JOY LLC	FACILITY NUMBER: 392700412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87707(a)(2)

(2) Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	Licensee will provide proof of classes completed for staff so that they are up to date for their training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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