392700640-11-29-2023-27-AS-KHOS-CZRNUY-20240123094708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700640
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:12:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2023 and conducted by Evaluator Albert Johnson

COMPLAINT CONTROL NUMBER: 27-AS-20231009140814

FACILITY NAME:	COURTYARD AT RIO LAS PALMAS, THE		FACILITY NUMBER:	392700640
ADMINISTRATOR:	GUERRERO, LIZETH		FACILITY TYPE:	740
ADDRESS:	877 EAST MARCH LANE		TELEPHONE:	(209) 957-4711
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	80	CENSUS: 59	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	10:41 AM
MET WITH:	L. Guerrero		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Licensee does not ensure facility is free from roaches.
Licensee does not ensure facility is in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson arrived to deliver findings for the above allegations. LPA met with Executive Director Lizeth Guerrero and explained the purpose of the visit.

Allegation: Licensee does not ensure facility is free from roaches.

Based on records reviewed, interviews with residents, staff and a tour of the kitchen including the dining room; the facility has not had any identified pest or rodent activity. This information was confirmed by ECOLAB customer service invoice reports for the months of October and November of 2023. The facility has a continued service agreement with ECOLAB to provide pest and rodent control. No visual or signs of activity of pest were observed by investigating LPA. Continued

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231009140814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COURTYARD AT RIO LAS PALMAS, THE	FACILITY NUMBER: 392700640
	VISIT DATE: 11/29/2023

NARRATIVE

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Allegation: Licensee does not ensure facility is in good repair.

Based on records reviewed and observation of the working elevators the department was able to confirm that on or about October 10, 2023, there was an automobile accident that cause a "Shorting of one leg to ground causing damage to the pump motor". This information was confirmed by service repair invoice from TK Elevator Corporation dated 10/10/23.

Although the elevator were down the facility provided accommodations to support the needs of the residents in care. The facility was without power on the 10th of October 2023 for approximately 2 hours. The facility was able to maintain power to the facility by use of the back-up generator.

Therefore, this complaint is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC9099 (FAS) - (06/04)

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