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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700640
Report Date: 01/09/2023
Date Signed: 01/09/2023 04:28:04 PM

Document Has Been Signed on 01/09/2023 04:28 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: 59DATE:
01/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lizette GuerreroTIME COMPLETED:
04:30 PM
NARRATIVE
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On 1/9/23 at approximately 2:00pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a case management visit in relation to an incident report received for a theft of resident funds. LPA Jensen met with Executive Director Lizette Guerrero and explained the purpose of today's visit.

On 1/1/23 a resident 1 (R1) was sent out to the hospital and left wallet with staff. Staff put the wallet in the narcotics drawer of the medication cart for safe keeping as it is double locked. When the resident returned and asked to retrieve the wallet it was noted that cash was missing.

LPA Jensen interviewed R1, the Executive Director and reviewed documentation related to the facility's internal investigation. Based on the interviews conducted with staff and R1. The contents of the wallet left for safe keeping was not documented. The facility does not routinely safe guard resident cash and did not have a written procedure in place for this set of circumstances.

Based on the records reviewed, the facility met the regulatory reporting requirements by completing an SOC 341, reporting to the police, Community Care Licensing, R1's family and the Ombudsman. There investigation is ongoing and the party responsible for the theft has not yet been identified.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/09/2023 04:28 PM - It Cannot Be Edited


Created By: Maja Jensen On 01/09/2023 at 02:58 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: COURTYARD AT RIO LAS PALMAS, THE
FACILITY NUMBER: 392700640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
Section Cited
CCR
87217(b)

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Safeguards for Resident Cash, Personal Property, and Valuables
Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources....This requirement was not met as evidenced by:
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The Licensee agrees to develop and implement a written procedure for the safeguarding of resident valuables in the event of an emergency that includes providing a written receipt for the valuables that are being safeguarded. The plan will be emailed to maja.jensen@dss.ca.gov by the POC due date.
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Based on interviews conducted and records reviewed, the facility did not adequately safeguard resindet cash or furnish a receipt for valuables in the Licensee's/facility's care. This poses a potential health, safety and personal rights risk to residents in care.
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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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023


LIC809 (FAS) - (06/04)
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