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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 08/04/2022
Date Signed: 08/05/2022 02:53:07 PM


Document Has Been Signed on 08/05/2022 02:53 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:MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTECFACILITY NUMBER:
392700473
ADMINISTRATOR:SHERYL BRAVOFACILITY TYPE:
740
ADDRESS:430 NORTH UNION RDTELEPHONE:
(209) 823-0164
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:84CENSUS: 61DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Analynn MadarangTIME COMPLETED:
02:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 08/04/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Health and Wellness Director Analynn Madarang who was briefly interviewed.
Current census was 61 residents.
Tour of this facility was conducted.
Living areas, dining areas, and all other areas intended for resident were toured and observed to contain adequate furniture and furnishings to meet the needs of the residents at this time.
Kitchen area was toured. Food supply was reviewed for adequate 7-day nonperishable and 2-day perishable food quantities. Food storage units were reviewed.
A tour of the resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Medication cabinets were reviewed in the main med room. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility employed a Medication Administration Record system to document and account for all of the medications being dispensed at this time. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time.
A tour of the facility memory care unit was not conducted at this time due to residents having COVID 19.
Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 01/27/2022 by the local fire extinguisher company noted as Johnson Controls and in compliance at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence and side gates was conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473
VISIT DATE: 08/04/2022
NARRATIVE
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The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was left with the Health and Wellness Director at this time.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/05/2022 02:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation by this LPA, the licensee did not comply with the section cited above in that the facility perimeter fence was falling down in sections and was in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Facility designated personnel stated that a work order will be commissioned and the fallen fence sections of the perimeter will be replaced/repaired as needed. A statement of correction, along with a copy of the work order and photos of the updated fence, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation by this LPA, the licensee did not comply with the section cited above since windows screens were torn, had holes, or were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Facility designated personnel stated that a work order will be commissioned and the window screens will be replaced/repaired as needed. A statement of correction, along with a copy of the work order, will be completed and submitted into CCL by the due date.

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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3