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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700451
Report Date: 02/03/2023
Date Signed: 02/03/2023 04:34:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/03/2023 04:34 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: 9DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stan Chesney TIME COMPLETED:
04:45 PM
NARRATIVE
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On 2/3/23 at approximately 2pm Licensing Program Analyst (LPA) arrived at facility unannounced to conduct a required 1 year visit. LPA Jensen met with Licensee Stan and Chris Chesney and explained the purpose of today's visit. Chris Chesney is the Administrator and she holds a current Administrator's certificate #6010320735. LPA Jensen verified there is no COVID positive residents or staff currently.

The facility is a two story building. There is a designated entrance set up for signing in visitors and COVID screening for staff and visitors. LPA Jensen observed COVID mitigation signs posted throughout as well as a personal rights, "See something, say something" , disaster plan and license. The facility was observed to be sanitary and odor free. There was adequate lighting and furnishings throughout the facility. A flashlight is mounted to the wall at several exits for emergency use. The facility maintains a first aid kit that is complete with scissors, tweezers, thermometer, first aid manual and various wound dressings. The fire extinguisher was last serviced in June of 2022 and is in compliance. The carbon monoxide was tested and found to be in good working order.

LPA Jensen toured two kitchens, the dining room, living room, bathrooms, laundry room and resident bedrooms. Staff was preparing meatloaf and vegetables for dinner. An activity calendar was posted with a variety of options for the residents. The facility was observed to have in excess of 2 days of perishable food and 7 days of non-perishable food. Knives, toxins, and medications were observed to be locked and inaccessible to residents in care. Medication Administration Records were reviewed and found to be in order. The care staff at the facility were all observed to be background cleared and associated to the facility. The thermostat was set to 72 degrees for the comfort of the residents

The bathrooms were observed to have grab bars and non-slip flooring. There are hand washing signs posted in the bathrooms. Continued on LIC 809C....




SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 02/03/2023
NARRATIVE
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There was emergency lighting observed in the bedroom halls. All bedrooms were observed to have a chair, dresser, night stand and a lamp for the convenience of the residents. LPA Jensen interacted with 3 of 9 residents and all residents observed appeared content and had their needs met. LPA Jensen reviewed staff files and resident files and found both to be complete and in compliance.

The grounds were observed to be well maintained and all paths were clear of obstruction. The grounds have ample space and furniture for outdoor activity. There is a swimming pool on site that is gated. The gate was observed to be unlocked. The Administrator locked the gate immediately in the presence of the LPA.

LPA Jensen requested and received an updated copy of the LIC 500 and liability insurance for the master file.

A civil penalty is being assessed on this day. An exit interview was conducted and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/03/2023 04:34 PM - It Cannot Be Edited


Created By: Maja Jensen On 02/03/2023 at 04:21 PM
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: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited
CCR
80087(e)

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Buildings and Grounds
All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement was not met as evidenced by:
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The licensee locked the swimming pool in the presence of the LPA. No further Plan of Correction is required.
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Based on LPA's observation of the gate surrounding teh swimming pool being unlocked. This poses an immediate threat to teh health, safety and personal rights of 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 King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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