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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700603
Report Date: 04/23/2025
Date Signed: 05/01/2025 04:54:25 PM

Document Has Been Signed on 05/01/2025 04:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AUSTIN ROAD HOMEFACILITY NUMBER:
392700603
ADMINISTRATOR/
DIRECTOR:		SHERRY PERRY-HYLTONFACILITY TYPE:
735
ADDRESS:16590 S AUSTIN RDTELEPHONE:
(209) 823-6061
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 3DATE:
04/23/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Sherry Hylton and Melinda WombleTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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A Noncompliance Conference (NCC) was conducted today on 04/23/2025, via Microsoft Teams. The purpose of the NCC was to discuss the Substantiated complaint of a violation of personal rights. Present at today’s NCC were the Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Charlie Yang, and facility designated Administrators Melinda Womble and Sherry Hylton, Katina Richison, and Brian Bennett from Valley Mountain Regional Center (VMRC). The administrative process was explained during this meeting and the facility designated Administrator was informed that further citations may result in Administrative Action.

The focus of the concerns at this time:
  • Administrator Qualifications and Duties
  • Facilities Policies and Procedures regarding 911 intervention
  • Observation of residents
  • Oversight of facility staff for proper care and supervision
  • Reporting Requirements
  • Updating policies and procedures for resident fall risks
  • Maintaining continued compliance
  • Facility agreed to TSP referral and assistance
  • Facility designated Administrator to be present at least 40 hours/week
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
VISIT DATE: 04/23/2025
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Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:
  • Complete and submit the LIC 500 for the most current staff, shifts, and coverage for designated shift leads
  • Complete and submit the LIC 308
  • Complete and submit the LIC 309, as well as, the most updated documents from the Secretary of State filing for this corporation
  • Complete and submit proof of most recent training in the areas of Resident Personal Rights, Resident Care, and Resident Supervision. Proof of submission to include name of trainer, topics covered with duration of training, and list of all attendees
  • Complete and submit proof of most recent training for proper completion of the LIC 624 for all staff by 04/30/2025
  • Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited at this visit. An exit interview was conducted with facility staff, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

The RO will increase monitoring. During these visits the RO will ensure the following:
  • All trainings are up to date.
  • The Administrator is present at agreed upon times documented on the LIC 500.
  • Medical intervention and observation procedures have been followed and staff are familiar with the requirements.
  • Reporting Requirements have been met.
  • The facility is compliant with rules and regulations.


Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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