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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 08/12/2021
Date Signed: 08/13/2021 03:06:11 PM

Document Has Been Signed on 08/13/2021 03:06 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: 51DATE:
08/12/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sheryl BravoTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt made an unannounced visit to the facility on this day for the purpose of conducting a Case Management Visit. LPA met with Administrator Sheryl Bravo and explained the reason for the visit.

On 08/11/2021 CCL was notified that the facility was previously experiencing a COVID outbreak that was not reported to the Department. The Administrator reported the last COVID positive in the facility was on 07/31/2021. Per CCL's records the last COVID was reported on 01/29/2021.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report along with appeals rights was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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Document Has Been Signed on 08/13/2021 03:06 PM - It Cannot Be Edited


Created By: Sarah Hurt On 08/12/2021 at 01:58 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: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/12/2021
Section Cited
CCR
87211(a)(2)

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Reporting Requirements.
(a) each licensee shall furnish to the licensing agency such reports as the Department may require, including but not limited to, the following:
(2) occurences, such as epidemic outbreaks, poisonings, catastrophes or major accidents
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Administrator will provide declaration of understanding of the regulation. Also training for all staff who submits incident reports.
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which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported wihin 24 hours either by telephone or facsimile to the licensing agency and local health department. This requirement has not been met as evidenced by Administrator showed LPA emails of reportings of COVID outbreaks and admittedly did not phone or fax. This poses an immediate risk to 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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021


LIC809 (FAS) - (06/04)
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