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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700557
Report Date: 09/09/2024
Date Signed: 09/10/2024 11:20:31 AM


Document Has Been Signed on 09/10/2024 11:20 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 LLCFACILITY NUMBER:
392700557
ADMINISTRATOR:LAJA, JOYFACILITY TYPE:
740
ADDRESS:119 N LINCOLN AVETELEPHONE:
(209) 239-5500
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:15CENSUS: 11DATE:
09/09/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Razn CadangTIME COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit made out to this facility on 09/09/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Razn Cadang. A brief interview was conducted with the facility staff person at this time. This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Joy Laja, to inform her that CCL was present at this time.
Current census was 11 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 08/14/2024. This visit was to follow up on the Plans of Correction that were due.
The following deficiencies were observed and cited on 08/14/2024:
  • 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.

  • 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. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

  • 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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: 09/09/2024
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This facility did complete the Plans of Correction and provided all of the required forms and documents at this time.
Plan of Correction clearance letters were printed and copies were provided to the facility staff person at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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