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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700557
Report Date: 12/08/2022
Date Signed: 12/09/2022 03:01:08 PM


Document Has Been Signed on 12/09/2022 03:01 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:GELZHEN GUEST HOME LLCFACILITY NUMBER:
392700557
ADMINISTRATOR:LAJA, JOYFACILITY TYPE:
740
ADDRESS:119 N LINCOLN AVETELEPHONE:
(209) 239-5500
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:15CENSUS: 7DATE:
12/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Teresita and Ferdinand GallaTIME COMPLETED:
11:30 AM
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Unannounced Plan of Correction visit made out to this facility on 12/08/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregivers, Ferdinand and Teresita Galla, who were briefly interviewed. This LPA requested that the facility caregivers go ahead and contact the Licensee/Facility designated Administrator to let him/her know that CCL was present at this time.
Current census was 7 residents.
The purpose of this visit was to clear the deficiencies that were cited on the previous complaint visit dated on 11/21/2022 for the following deficiencies:

Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents' money or interfering with daily living functions such as eating, sleeping, or elimination.

This LPA requested that the following forms and documents to be updated and completed and submitted into CCL for review by this LPA:
  • LIC 308
  • LIC 400
  • LIC 500
  • LIC 610


Plan of correction letter was printed and a copy was given to the facility caregivers at this time.
There were no additional deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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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