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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:34:54 PM

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: 49DATE:
11/30/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sheryl BravoTIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citation issued during the annual inspection/survey on 11/01/2021.

Deficiency cited under Title 22 Regulations has been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter.

During LPA Johnson health and safety check, LPA and Med-Tech observed missing documentation for controlled medication count for 10/29/21 off going PM, 10/30/2021 off going PM, 11/6/2021 off going AM, 11/18/2021 off going AM, 11/22/2021 off going AM, 11/23/2021 NOC, 11/24/2021 off going AM and 11/25/2021 off going AM.

Based on the above information a citation will be given for missing documentation.

Exit interview conducted and a copy of this report with appeal rights was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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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: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/01/2021
Section Cited

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(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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(4) Assistance with prescribed medications which are self-administered.This requirement was not met as evideniced by records reviewed residents records for controlled medication count has missing documentation this is a safety risk to residents in care.
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and submit copies of the trainer with a complete training list of individuals to Licensing by POC date,12/01/2021

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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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