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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700640
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:53:56 PM

Document Has Been Signed on 07/07/2021 02:53 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:COURTYARD AT RIO LAS PALMAS, THEFACILITY NUMBER:
392700640
ADMINISTRATOR:GUERRERO, LIZETHFACILITY TYPE:
740
ADDRESS:877 EAST MARCH LANETELEPHONE:
(209) 957-4711
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 80CENSUS: 63DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:LIzeth GuerreroTIME COMPLETED:
12:00 PM
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On 07/7/2021 at 8:45am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Administrator Lizeth Gurrero regarding facility risk assessment questions who confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:45am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 80 non ambulatory residnets, today's census is 63, 9 hospice residents in compliance with licensure and fire clearance. 6 of 6 staff observed cleared and associated in Licensing Information System. Administrator certificate expires on 6/19/2022.

LPA interacted with a random number of residents during this visit and observed residents engaging in communal dining and activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, staff offices, and common restrooms. LPA observed facility last conducted disaster drill on 6/30/2021. The temperature inside the facility was measured at 76*F is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. The hot water was measured at 118*F which is not less than 105*F and not more than 120 *F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA reviewed two MAR's to document medications administered per physicians order. The first aid kit was found in compliance containing: a current edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.


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SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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: COURTYARD AT RIO LAS PALMAS, THE
FACILITY NUMBER: 392700640
VISIT DATE: 07/07/2021
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LPA observed a pull alarm system, fire extinguisher inspected on 9/11/2020, smoke and carbon monoxide detectors, central heating and air in the facility, fixed fire suppression system last biannual inspection conducted on 3/12/2021. LPA observed elevator last annual inspection conducted on 10/21/2020. LPA observed emergency evacuation chair lift in stairwell. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed knives and toxins inaccessible to residents.

LPA observed COVID precautions and PPE available and stored for facility staff.

Upon a file review the following items were discussed to be submitted with any changes annually to be submitted by 7/30/2021.

Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Administrator Certificate expires on 6/19/2022.
Emergency Disaster Plan LIC610E
First aid/CPR certificate

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, a signature on this form acknowledges receipt of these documents and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC809 (FAS) - (06/04)
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