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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700729
Report Date: 02/17/2022
Date Signed: 02/17/2022 02:44:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/17/2022 02:44 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:YANNICA GUEST HOMEFACILITY NUMBER:
392700729
ADMINISTRATOR:MARTIN, MAXIMAFACILITY TYPE:
740
ADDRESS:2329 DIAMOND OAKS STREETTELEPHONE:
(510) 366-6585
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:M. MartinTIME COMPLETED:
03:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and Maxima Martin and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 115 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed medication for R1 empty and no replacement medication or refill was in place. LPA reviewed resident and staff files, including criminal record clearances. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

Pursuant to Title 22 rules and regulations, Health and Safety Codes, a citation was given.

Exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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 02/17/2022 02:44 PM - It Cannot Be Edited

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: YANNICA GUEST HOME
FACILITY NUMBER: 392700729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited

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87465(c)(2) Incidental Medical and Dental Care-designated by the licensee shall Once ordered by the physician the medication is given according to the physician's directions
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This requirement was not met as evidenced by missing medication for R1 which poses an immediate health and safety issues for R1.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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