392700557-8-20-2024-27-AS-CYAG-D8BNRN-20240820104148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700557
Report Date: 08/14/2024
Date Signed: 08/20/2024 10:42:00 AM

Document Has Been Signed on 08/20/2024 10:42 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:	GELZHEN GUEST HOME LLC		FACILITY NUMBER:	392700557
ADMINISTRATOR:	LAJA, JOY		FACILITY TYPE:	740
ADDRESS:	119 N LINCOLN AVE		TELEPHONE:	(209) 239-5500
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	15	CENSUS: 7	DATE:	08/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Joy Laja		TIME 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 08/14/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Joy Laja, who was briefly interviewed at this time. Current census was 7 residents. 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 (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (2) residents diagnosed with dementia at this time. It was learned that there was (1) resident receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, 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. Linen closets, located in the facility hallway closets, were reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Additional food storage units were observed to be present and functional at this time. Pantry was also reviewed as well. Laundry area, located in the facility kitchen area, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 6045273740, for Joy Laja was observed to have an expiration date of 08/31/2025

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
	VISIT DATE: 08/14/2024

NARRATIVE

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and in compliance at this time.
Medication cabinet, located in the facility kitchen area, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the kitchen cabinet, was reviewed. This LPA observed that it did 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, Nor Cal Fire, on 06/18/2024 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted.
A review of the facility perimeter fence, side gates, and all other exits was conducted.
This LPA observed an additional storage shed that were present on the south side of this facility at this time. This storage shed was observed to be locked and made inaccessible to the residents at this time.

A review of (3) facility personnel records was conducted on the LIC 859.
A review of (5) facility resident records was conducted on the LIC 858.

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: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2024 10:42 AM - It Cannot Be Edited

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Observation of the Resident


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

Type A

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [3] facility personnel files did not contain the required courses and hours of annual training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility personnel providing care and supervision to the residents will undergo the proper courses of training and obtain the adequate number of hours. A statement of correction, along with copies of the number of courses and number of hours of training, will be completed and submitted into CCL by the due date for review by this LPA.

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: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2024 10:42 AM - It Cannot Be Edited

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that [1] out of [5] facility resident files did not contain an updated annual medical assessment to address any possible changes to their care needs related to dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all residents diagnosed with dementia will be scheduled with their responsible licensed medical professionals to undergo a medical assessment and update the LIC 602. A statement of correction, along with copies of the updated LIC 602s, will be completed and submitted into CCL by the due date for review by this LPA.

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: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2024 10:42 AM - It Cannot Be Edited

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 there was a hole in the facility resident restroom floor that was covered by a brick which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a plan will be conducted to hire licensed professionals to fix the hole and replace the flooring as required. A statement of correction, along with copies of the receipt for the hired professionals completed work, will be completed and submitted into CCL by the due date for review by this LPA.

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: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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