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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700640
Report Date: 03/01/2022
Date Signed: 03/01/2022 12:50:06 PM


Document Has Been Signed on 03/01/2022 12:50 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: 134DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lizeth GuerreroTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Maja Jensen and Avelina Martinez arrived unannounced at facility on 3/1/22 at 9:45am for a one year required annual visit. LPAs spoke with Administrator Lizeth Guerrero and informed her of the purpose for today's visit. Upon entering the facility risk assessment questions were asked and LPAs confirmed there are no active COVID cases at this time. The facility is licensed to serve a total capacity of 80 non ambulatory residents, today's census is 64 with 10 hospice residents in compliance with licensure and fire clearance. 7 of 7 were staff observed cleared and associated in Licensing Information System. Administrator's certificate expires on 6/19/2022.

LPAs toured the physical plant inside and outside to ensure the safety of the residents. LPAs observed a resident room, restrooms, nurse's room where medication is stored, dining room, activity areas, patio, kitchen, staff offices, and common restrooms. There is a coy pond at the resident patio that is surrounded by a wrought iron fence and locked. The patio was clean and clear of hazards. The front entrance of the facility has a water feature covered with plexiglass for resident safety. LPA verified the last fire drill was conducted 2/28/22. The temperature inside the facility was measured between 74 and 78 degrees which is within the required range of 68*F and 85*F. LPAs Maja Jensen and Avelina Martinez reviewed 3 staff files and 3 resident files which were observed to be complete with all necessary documentation. LPAs observed COVID related signs and sanitizer posted along the walls throughout the facility. LPAs also observed "see something, say something", Ombudsman and personal rights signs posted in a high visibility area of the facility.

LPAs observed lunch service and engaged with various residents throughout the facility. LPAs observed three refrigerators ranging in temperature from 35 to 41 degrees. LPAs also observed the freezer and dry pantry to be organized and sanitary. There is a menu posted daily and vegetarian options are offered. LPAs observed the facility to have in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food along with emergency supplies. The kitchen fire suppression system was inspected 9/21/22 and is in compliance.
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SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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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: 03/01/2022
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LPAs observed the kitchen hood to be clean and sanitary and was last inspected in December of 2021. The dishwashing area was observed to be sanitary and a dish temperature log is maintained and was observed to have consistent temperature readings of approximately 160 degrees. The employee breakroom was observed to be clean and in good repair with hand washing signs posted. A computer room was observed for residents with access to internet and in compliance with legislation.

LPAs observed a second dining room that is being remodeled with access restricted to contractors only. The remodel is scheduled for completion on 3/2/22. LPAs observed mask signs posted in elevators. LPAs observed carbon monoxide and fire alarms throughout the facility.

LPAs observed a dip in the floor on the second level and a dip on the third level. Administrator Lizeth Guerrero advised that the facility is the process of leveling and replacing carpet on the second. LPA Maja Jensen has asked facility to also level the flooring on the third level of the facility by the main elevator. LPA Maja Jensen has requested evidence of repair on the second floor by 3/15/22 and a bid for the third floor leveling.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. Exit interview was held, a signature on this form acknowledges receipt of these documents and a copy of report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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