392700473-2-23-2026-27-AS-APAA-DRKVGF-20260223152527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 02/23/2026
Date Signed: 02/23/2026 03:25:55 PM

Document Has Been Signed on 02/23/2026 03:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR/ DIRECTOR:	JAMES HALL		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY: 84		CENSUS: 51	DATE:	02/23/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	James Hall		TIME VISIT/ INSPECTION COMPLETED:	03:45 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	On 02/23/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua met with Business Office Manager (BOM), Goshang Vang and explained the purpose of the visit. It was learned at this time that Facility Designated Administrator (FDA), James Hall was out of the office at this time and would meet LPA Pascua at a later time. At 2:45PM LPA Pascua was met by FDA James Hall. This facility is licensed to serve and retain 58 ambulatory residents and 26 non-ambulatory residents. This facility also has a dementia plan in file and a holds a hospice waiver for 10 residents. Current census was 51. A brief interview with FDA Hall was conducted. FDA Hall has a current and active administrator certificate #7014180740 and expires on 11/19/2027 LPA Pascua reviewed 5 staff files. 5 out 5 staff files were complete and up to date. LPA Pascua reviewed 6 resident files. It was observed that 1 out 6 residents did have an updated care plan, however, review of this resident's medical assessment showed that the resident's needs were not properly identified as assessed by the facility. Technical Assistance was provided regarding Dementia Regulations, resident assessments, and best practices regarding these topics. A brief tour of the facility was conducted. Due to insufficient time to review additional files. The department will come at a later date to complete the annual visit. The following forms were obtained during this visit: LIC308, LIC400, LIC 500, and LIC610E. There were no deficiencies observed or cited during today's annual visit. An Exit Interview was conducted and a copy of this report was provided to the administrator at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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