392700626-7-3-2023-27-AS-CYAG-CTDLS2-20230703090001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700626
Report Date: 06/28/2023
Date Signed: 07/03/2023 09:13:14 AM

Document Has Been Signed on 07/03/2023 09:13 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	NATIONAL SAN JOAQUIN		FACILITY NUMBER:	392700626
ADMINISTRATOR:	VALERIE VOIL		FACILITY TYPE:	772
ADDRESS:	401 SOUTH AIRPORT WAY		TELEPHONE:	(916) 238-1619
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY: 14		CENSUS: 5	DATE:	06/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gurpreet Kaur		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 06/28/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Program Manager Gurpreet Kaur and the facility nurse De la Milagros Plaza. Brief interview was conducted the facility program manager and facility nurse at this time. It was learned that the facility Program Director, Elizabeth Sauers, was unable to be present for the annual visit with CCL at this time. LPAs set up in a separate pod building in the rear of this facility. Current census was 5 residents. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed for an adequate supply of plates, silverware, and other items intended for use by the residents. Food supply was reviewed for an adequate supply of 2-day perishable and 7-day nonperishable food quantities at all times. LPAs observed several food storage units within this facility in the form of additional refrigerator and freezer units. Medication room was toured. LPAs observed the use of a medication cart that was locked and made inaccessible to the residents at all times. This facility employed the use of an E-MAR system, Point Click Care, to dispense, manage, and document all medications for the residents at this time. First aid kit was observed to be present and contained all of the required components at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 05/02/2023 by the local fire extinguisher company, Armor Fire Extinguisher Company, and in compliance at this time. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident restrooms (3) was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NATIONAL SAN JOAQUIN	FACILITY NUMBER: 392700626
	VISIT DATE: 06/28/2023

NARRATIVE

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A tour of the laundry area was conducted. It was learned that residents were scheduled on a weekly basis to wash and dry their own clothes with the assistance of facility staff if necessary. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the common areas was conducted. Living area, dining area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the staff break room and separate staff restroom was conducted.
A tour of the exterior grounds was conducted. Storage sheds were observed to be present and in use at this time. It was learned that client belongings were inventoried and stored in bins in one of the sheds.
Cleaning supplies and items used to repair and upkeep this facility were also stored in another shed unit as well. All of the shed units were observed to be locked and made inaccessible to the residents at this time.
Facility perimeter fence, side gates, and all exits were reviewed.

The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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 provided unto the facility Program Manager at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/03/2023 09:13 AM - It Cannot Be Edited

Created By: Charlie Yang On 06/28/2023 at 01:32 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: NATIONAL SAN JOAQUIN	FACILITY NUMBER: 392700626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81066(c)

The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 [4] out of [5] facility personnel records were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/05/2023
	Plan of Correction
1 2 3 4	Facility program manager stated that all facility personnel records will be updated to contain all of the required forms and documents. A statement of correction, along with copies of the updated files that were missing, will be completed and submitted into CCL by the due date.

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

LICENSING EVALUATOR NAME:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC809 (FAS) - (06/04)

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