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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700451
Report Date: 09/01/2021
Date Signed: 09/01/2021 12:07:06 PM

Document Has Been Signed on 09/01/2021 12:07 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHESNEY PROFESSIONAL CAREFACILITY NUMBER:
392700451
ADMINISTRATOR:CHESNEY, CHRISFACILITY TYPE:
735
ADDRESS:7163 UYEDA RDTELEPHONE:
(209) 403-8948
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 15CENSUS: 10DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cristal FonsecaTIME COMPLETED:
12:15 PM
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On 9/1/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection at 9:15am and met with Staff Designee (S1). Administrator and Licensee were not able to be on site during today's inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 clients, today's census 10, and accompanied by S1 throughout today's inspection. Two of two staff observed on site with criminal record clearance and associated in Licensing Information System. Person 1 (P1) observed residing in the facility in staff room with criminal record clearance. LPA contacted Regional Office and staff associated P1 to the facility on today's date. LPA observed Administrator Certificate expires on 2/17/2022.

LPA interacted with a random number of clients during this visit. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, laundry rooms, restrooms, bedrooms, and common living areas and backyard, LPA observed items stored not in use or good repair in backyard including a ladder, bed, boxes, backdoor screen torn, tomato cages, wood post, uncoiled hose, and broken pots. Observed one of four exterior structurse not in good repair with cigarette butts inside, S1 stated Resident one (R1) uses in it the winter to smoke inside. LPA observed medications, toxins, and knives stored locked in accessible to clients. LPA observed the pool gates locked and in accessible to clients. The temperature inside the facility was measured at 74*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 111.2*F within regulatory range of not less than 105*F and not more than 120*F. LPA observed newly installed hot water dispenser at kitchen sink in staff area kitchen measured at 140.8*F. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days maintained on site.
Continued on 809 C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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: CHESNEY PROFESSIONAL CARE
FACILITY NUMBER: 392700451
VISIT DATE: 09/01/2021
NARRATIVE
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Continued from 809.

LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and posted hand washing signs. 30 day supply of PPE stored on site. S1 stated common surfaces are disinfected three times daily and inbetween use. LPA observed hand sanitizer available throughout the facility.

Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds. LPA observed fire extinguisher last inspected on 4/16/2021, pull alarm system, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed fire suppression system last annual inspection conducted in June 2020 past due. LPA observed facility is on private water supply, S1 stated last inspection was August 2021 and the report not available as of today's date. LPA observed the facility conducts fire drills documented monthly.

Upon a file review the following items were discussed to be submitted to LPA by 9/17/2021:
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Affidavit Regarding Client Cash Resources LIC400
Surety Bond LIC402
Facility Floor Plan/Plot Plan LIC999
Administrator Certificate
Emergency Disaster Plan LIC610D
Bacteriological Analysis of Private Water Supply

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/01/2021 12:07 PM - It Cannot Be Edited


Created By: Ashley Boothe On 09/01/2021 at 11:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHESNEY PROFESSIONAL CARE
FACILITY NUMBER: 392700451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that the fire fire suppression system last annual inspection conducted in June 2020 past due which poses an immediate health, safety or personal rights risk to persons in care.

****Civil Penalty assesed on today's date****
POC Due Date: 09/02/2021
Plan of Correction
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The licensee agrees to scheudle inspection and notify LPA of date scheudled by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 King
LICENSING EVALUATOR NAME:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/01/2021 12:07 PM - It Cannot Be Edited


Created By: Ashley Boothe On 09/01/2021 at 11:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHESNEY PROFESSIONAL CARE
FACILITY NUMBER: 392700451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that items stored on property not in use or good repair in backyard including a ladder, bed, boxes, backdoor screen torn, tomato cages, wood post, uncoiled hose, and broken pots. Observed one of four exterior structures not in good repair with cigarette butts inside, S1 stated Resident one (R1) uses in the winter to smoke inside which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2021
Plan of Correction
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The licensee agress to remove, repair or replace items stored not in use or good repair and submit pictures to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 King
LICENSING EVALUATOR NAME:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
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