<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700665
Report Date: 09/24/2021
Date Signed: 09/24/2021 01:42:40 PM

Document Has Been Signed on 09/24/2021 01:42 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:LAV MANORFACILITY NUMBER:
392700665
ADMINISTRATOR:ARVIN VILLANUEVAFACILITY TYPE:
735
ADDRESS:6411 KERMIT LANETELEPHONE:
(209) 473-4250
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Arvin VillanovaTIME 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
On 9/24/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a required 1-year Annual inspection. LPA COVID screened upon entry to the facility. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents. Today's census is 4. LPA observed four of four staff observed on site with criminal record clearance in Licensing Information System. LPA observed Licensee's Administrator Certificate expires on 1/3/2023 and Administrator's Administrator Certificate expires on 5/25/2022.

LPA interacted with a random number of residents during this visit and observed residents. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, restrooms, bedrooms, and common living areas to be in good repair. LPA observed items stored not in use in shed and side yard including wheelchairs and client equipment. The temperature inside the facility was measured at 76*F which 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 at 84*F in restroom and 96*F in kitchen not within regulatory range which is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications, toxins, and knives to be locked inaccessible to residents. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA observed fire extinguisher last inspected on 6/15/2021, pull alarm system, smoke and carbon monoxide detectors, central heating and air in the facility. 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 COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash can and 30 day supply of PPE stored.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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 5
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: LAV MANOR
FACILITY NUMBER: 392700665
VISIT DATE: 09/24/2021
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
26
27
28
29
30
31
32
The facility has an approved Mitigation Plan.

Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds. LPA observed the facility conducts fire drills documented monthly.

Upon a file review the following items were discussed to be submitted to LPA by 10/15/2021:
Personnel Report LIC500
Designation Form LIC 308
Surety Bond LIC402
Affidavit Regarding Cash Resources LIC400
Emergency Disaster Plan LIC610D
Health Screening Report-Facility Personnel LIC503
First aid/CPR certificates
Qualifications of Administrator

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/24/2021 01:42 PM - It Cannot Be Edited


Created By: Ashley Boothe On 09/24/2021 at 01:09 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: LAV MANOR
FACILITY NUMBER: 392700665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that the hot water was measured at 84*Fin restroom and 96*F in kitchen not within regulatory range which is not less than 105*F and not more than 120*F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2021
Plan of Correction
1
2
3
4
The Licensee agrees to purchase new thermometer in working order, submit proof of water temperature correction, and a plan to maintain complaince with this regulation to LPA by POC 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:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5