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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700608
Report Date: 09/15/2022
Date Signed: 10/05/2022 02:12:44 PM

Document Has Been Signed on 10/05/2022 02:12 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:COOKS CARE RESIDENTIAL FACILITYFACILITY NUMBER:
392700608
ADMINISTRATOR:COOKS, MICHAELFACILITY TYPE:
735
ADDRESS:2546 NAPOLI CTTELEPHONE:
(209) 817-4860
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:M. CookTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Albert Johnson and Kesha Lewis arrived unannounced to conduct an annual inspection. LPAs met with Michael Cook and explained the purpose of the visit.

LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPAs observed sufficient furniture and lighting throughout the facility. LPAs observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 132.5 not within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPAs observed centrally stored medications are kept locked and inaccessible to residents. LPAs reviewed and compared resident medication vs. resident medication logs. LPAs reviewed 3 resident and 2 staff files, including criminal record clearances. During the file review for the residents LPAs observed that R1 went to the ER for abrasions on 8/31/22. The abrasions were as a result of a restraint on R1. (Advisory given)

The first aid kit was checked and is complete. LPAs observed carbon monoxide detectors in the facility. Fire drill was conducted

Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and appeal rights given
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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Document Has Been Signed on 10/05/2022 02:12 PM - It Cannot Be Edited


Created By: Albert Johnson On 09/15/2022 at 12:23 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: COOKS CARE RESIDENTIAL FACILITY
FACILITY NUMBER: 392700608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment and Supplies: Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C)
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Licensee will adjust the water heater to obtain a running water temperature between 105 to 120 degrees today.
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and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by: The hot water temperature in the consumer bathroom was at 132.5 degrees F. This poses a health and safety risk to residents in care
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 Licensee will check water temperature using a thermometer and will maintain a water temperature log for 3 days. Licensee will submit a copy of the log to CCL by 9/19/22.

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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: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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