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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 05/19/2023
Date Signed: 05/24/2023 10:53:18 AM

Document Has Been Signed on 05/24/2023 10:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 3DATE:
05/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Joseph NimeneTIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Albert Johnson arrived at the facility today to conduct a case management visit to follow up on an incident report that was submitted to Community Care Licensing.

The report detailed an AWOL from a new resident that was placed on respite from his parents/private residence. The resident in question has a history of contacting the police department and making false allegations about himself or others

The placement agency informed the facility that the requirement of a health screening prior to placement was not required because this was an emergency placement. This however is not a true statement.

The facility is required to have a medical assessment. The assessment is required to have the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. (2)Identification of the client's special problems and needs.(3)Identification of any prescribed medications being taken by the client.(4)A determination of the client's ambulatory status, as defined by Section 80001(n)(2). (5) Identification of physical restrictions, including any medically necessary diet restrictions, to determine the client's capacity to participate in the licensee's program. Although some of this information is included in the IPP, the results of an examination for communicable tuberculosis and other contagious/infectious diseases is not part of the information that was provided to the facility. Continued
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
VISIT DATE: 05/19/2023
NARRATIVE
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The AWOL incident was reported to the department and VMRC as required by the facility, however the Physician's report was not and still is not available for review either because it was not completed or has not been given to the facility.

This is an immediate safety risk for residents in care. Again, The facility requested a copy of the Physician's Report and was told by the representative of the Regional center emailed that:

" Sorry, since it was an emergency respite a physical and TB test were not obtained."

A deficiency was cited. A copy of this report and exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 10:53 AM - It Cannot Be Edited


Created By: Albert Johnson On 05/19/2023 at 12:58 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2023
Section Cited
CCR
80069(b)(1)(c1-5)

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80069 Client Medical Assessment
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
(1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
(c) The medical assessment shall include the following:
(1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.(2) Identification of the client's special problems and needs.

(3) Identification of any prescribed medications being taken by the client.

(4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).
(5) Identification of physical restrictions, including any medically necessary diet restrictions, to determine the client's capacity to participate in the licensee's program. This requirement was not met by records review
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The facility will take the resident toTB test and physical completed today.
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The placement agency informed the facility that the requirement of a health screening prior to placement was not required because this was an emergency placement. This is an immediate safety risk.
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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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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