392700473-2-27-2025-27-AS-CYAG-DEAMG2-20250227083513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 02/20/2025
Date Signed: 02/27/2025 08:35:40 AM

Document Has Been Signed on 02/27/2025 08:35 AM - 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 54	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	James Hall		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	Unannounced annual visit made out to this facility on 02/20/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, James Hall, who was briefly interviewed at this time. It was learned that there were (4) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (10) residents at any given time. It was learned that there were (14) residents diagnosed with dementia at this time. This facility does have an approved program to be able to accept and retain residents diagnosed with dementia at any given time. This facility does have a memory care unit on site at this time. Current census was 54 residents for both the Assisted Living and Memory Care portions of this entire facility. Tour of the facility was conducted. A tour of the facility kitchen area was conducted. Food storage units, refrigerator and freezer, were toured. It was observed that there was a sufficient supply of 2-day perishable food quantities available on site to meet the requirements at this time. Pantry area was toured. It was observed that there was a sufficient supply of 7-day nonperishable food quantities available on site to meet the requirements at this time. A sample review was conducted for the facility resident bedrooms at this time. It was observed that furniture and furnishings were observed to be functional and maintained in compliance at this time. A sample review was conducted for the facility resident restrooms at this time. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times. Grab bars and non skid surfaces were observed to be present and maintained in compliance at this time. Living areas, dining areas, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Laundry rooms, located throughout several wings of this facility on the first floor, were toured. They were observed to be unlocked but did not house any detergents, bleach, or cleaning supplies at this time. Rooms designated as supply rooms, storage rooms, and equipment rooms were observed to be locked and

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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
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
	VISIT DATE: 02/20/2025

NARRATIVE

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made inaccessible to the residents at this time.
Exercise room was toured. Equipment and supplies were observed to be sufficient and able to meet the needs of the residents at this time.
Medication room was toured alongside the facility nurse, Karen Silva, at this time. Policies and procedures in regards to the handling, dispensing, and documentation of the resident medications were discussed with her at this time. This facility utilized mobile medication carts that were pushed out into the facility when it was time to dispense the medications to the residents.
It was learned that this facility employed an E-MAR system as well as documented paperwork for the facility resident medications at this time.
First aid kit, located in the medication room, was observed to contain all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Johnson Controls, on 02/27/2024 and found to be in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the perimeter fence, side gates, and all other exits was conducted at this time.

A review of (7) facility resident files was conducted and noted on the following LIC 858.
A review of (7) facility personnel files was conducted and noted on the following LIC 859.

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

LIC 308
LIC 400
LIC 500
LIC 610

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 given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/27/2025 08:35 AM - It Cannot Be Edited

Created By: Charlie Yang On 02/20/2025 at 01:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that a portion of the facility perimeter fence had fallen down and was in need of repair/replacement. Also it was observed that unused furniture items and discarded shower chair and bathroom chair were left out which needed to be removed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the facility perimeter fence will be repaired/replaced. In addition, all unused items such as old furniture and resident furnishings will be removed from the premises. A statement of correction, along with photos of the repaired fence and cleared back area of this facility, will be completed and submitted into CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

TELEPHONE: (650) 676-0442

LICENSING EVALUATOR NAME:

Charlie Yang

TELEPHONE: (916) 709-6507

LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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