392700665-9-14-2023-27-AS-MJEN-CVNVZJ-20230914165248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700665
Report Date: 09/14/2023
Date Signed: 09/14/2023 04:52:56 PM

Document Has Been Signed on 09/14/2023 04:52 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 MANOR		FACILITY NUMBER:	392700665
ADMINISTRATOR:	JOYCE VILLANUEVA		FACILITY TYPE:	735
ADDRESS:	6411 KERMIT LANE		TELEPHONE:	(209) 473-4250
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY: 6		CENSUS: 3	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Joyce Villanueva		TIME COMPLETED:	05:00 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 9/14/23 at approximately 1:40pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Joyce Villanueva and explained the purpose of today's visit. The Administrator has an Administrator's certificate that is current. LPA Jensen toured the grounds and observed all paths to be clear of obstruction. There is a large shaded are with outdoor furniture for client use in the front of the property and walk ways and garden beds in the backyard. The AC unit is located on the roof and is dripping water that is being directed in to a bucket on the ground. The AC unit is functional at this time. LPA Jensen toured the interior of the facility. The facility was adequately lit and furnished. Toxins and knives are locked and inaccessible to residents in care. The carbon monoxide detector and smoke detectors were tested and are in compliance. The fire extinguisher was last serviced in June of 2023 and is in compliance. The first aid kit was determined to be complete. The water temperature was measured at 114 degrees Fahrenheit and is in compliance. The thermostat was set at 78 degrees which falls within the required regulatory range of 68-85 degrees Fahrenheit. The facility conducts regular fire drills. The emergency disaster plan was reviewed and is in compliance. The facility currently has 4 staff members and 3 clients. 2 of 3 clients have restricted health conditions. All clients have special diets. The plan of operation was reviewed and technical assistance is being provided address consistency between the plan of operation and the restricted health care plans. All staff and client files were reviewed and determined to be complete and in compliance. A random audit of the medication was conducted and the record keeping was observed to be accurate. LPA Jensen also conducted an audit of P&I funds and determined the accounting to be accurate. The facility has 4 bedrooms, 3 of which are for clients and 1 for live in staff. The client bedrooms were not equipped with chairs and technical assistance is being provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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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Document Has Been Signed on 09/14/2023 04:52 PM - It Cannot Be Edited

Created By: Maja Jensen On 09/14/2023 at 04:05 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: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's observation of laminate flooring buckling in dining room adn living room, water dripping from AC unit and bathroom caulking disrepair, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to submit a plan by 9/28/23 for facility improvements to be completed by 12/14/23.

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:

Maja Jensen

LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

Page: 2 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: 09/14/2023

NARRATIVE

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LPA toured the kitchen and observed an adequate supply of perishable and non-perishable food. The kitchen dishwasher is non-operable. There is fresh fruit and vegetables available. There are several activities maintained throughout the facility for client engagement. The facility maintains an adequate supply of linens and hygiene supplies. There are grab bars and in the bathroom and non-slip mats or surfaces in the bath/shower area. LPA Jensen observed the bathroom caulking to be separating away from the wall. There is laminate flooring throughout the house that is buckling and showings of wear.

LPA Jensen requested and received an updated LIC 500 and Liability insurance.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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