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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700719
Report Date: 11/09/2022
Date Signed: 11/09/2022 11:17:13 AM

Document Has Been Signed on 11/09/2022 11:17 AM - 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:OPENDOOR SERVICESFACILITY NUMBER:
392700719
ADMINISTRATOR:NAKAWATASE, JOHNFACILITY TYPE:
775
ADDRESS:1129 ENTERPRISE STTELEPHONE:
(209) 475-1529
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 165CENSUS: 91DATE:
11/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sherry Welker-LozaTIME COMPLETED:
11:45 AM
NARRATIVE
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On 11-9-22 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding a reported incident occurring on 9-21-22. LPA met with Program Director (PD) Sherry Welker-Loza and explained the purpose of the visit. LPA interviewed PD and reviewed incident report with PD. Based on interview and record review, it was determined that Resident1 (R1) and R2 were engaged in a physical altercation in which R1 hit R2 with a closed fist on the right side of his face and scratched R2 as well, leaving a minor injury.

Further review and interview revealed that licensing department and responsible party for R1 and R2 were notified, however, local law enforcement and ombudsman were not notified per regulatory requirements.
Based on today's case management, deficiency were cited under Title 22, Division 6 and noted on LIC 809D

An exit interview was conducted with Sherry Welker-Loza and a copy of this report was left with Sherry. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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Document Has Been Signed on 11/09/2022 11:17 AM - It Cannot Be Edited


Created By: Michael Bilger On 11/09/2022 at 10:53 AM
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: OPENDOOR SERVICES
FACILITY NUMBER: 392700719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
82061(c)

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Reporting Requirements. (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the...ombudsman...corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...
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Licensee will conduct staff training on reporting requirements; regulation 82061 and submit proof of completed training to LPA by POC due date.
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This requirement is not met as evidenced by: Based on interview and record review, R1 and R2 were engaged in a physical altercation which was not reported to ombusdsman and law enforcement. This poses a potential health, safety, and resident 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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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