392700729-11-15-2024-27-AS-RCAL-DB2TSY-20241115135954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700729
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:00:03 PM

Document Has Been Signed on 11/15/2024 02:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	YANNICA GUEST HOME		FACILITY NUMBER:	392700729
ADMINISTRATOR/ DIRECTOR:	OBTINALLA, MICHELL		FACILITY TYPE:	740
ADDRESS:	2329 DIAMOND OAKS STREET		TELEPHONE:	(209) 565-5873
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Maxima Martin, Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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On 11/15/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct an annual inspection. LPA Campbell met with Licensee Maxima Martin and explained the purpose of the visit. Administrator Michell Obtinalla's administrator certificate (# 6066972740) is current and they are associated to the facility. Upon arrival, LPA Campbell observed a one story house surrounded by a white metal fence with sliding access that could be pushed open. The facility is licensed to served 6 ambulatory residents who are 60 and over. Of the 6 residents, 5 may be non-ambulatory and 1 may be bedridden. There is a hospice waiver for 6. The home has four resident bedrooms, 2 bathrooms and a staff room.

The entrance of the facility opens into a living room with a couch, mirrors and coffee table. There is then a kitchen and TV room. One resident was observed watching television and singing along with a song. Two informational posters were observed. They included a "See Something, Say Something" poster and a "Long Term Care Ombudsman" poster with contact information. The refrigerator contained three days of perishable foods. One staff was observed mopping the hallway leading to residents rooms. LPA Campbell toured the rest of the facility and observed 6 residents in four bedrooms. Bedroom #2 had a single resident. The rest of the residents were paired up to share.

The staff room contained the washer and dryer, cleaning products and the pantry for the facility. There were enough non-perishable foods to last 7 days. All rooms were free of odor and debris. Pathways were unobstructed.

Lisa Rios	TELEPHONE: (916) 969-9685
Renee Campbell	TELEPHONE: (916) 206-6380
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: YANNICA GUEST HOME	FACILITY NUMBER: 392700729
	VISIT DATE: 11/15/2024

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A thermostat was set at 68 degrees Fahrenheit (F) which is within the required range of 68 and 85 degrees. A fire extinguisher in the living room was last inspected on January 8, 2024. The facility sketch reflects that no changes have been made to the facility structure. Smoke and carbon monoxide alarms were tested and found to be functioning. Water from the bathroom faucet was observed to be 110.1 degrees F and water from the kitchen faucet was measured at 116.7 degrees F. Both measurements are within the required range of 105 and 120 degrees.

During a tour of the backyard, LPA Campbell observed an orange tree bearing fruit. The fire exit was without obstruction. There was a shaded seating area directly outside of the sliding glass doors and several plants ran along the fence border. The backyard was free of debris.

LPA Campbell reviewed 5 of 6 client files and 5 of 5 staff files. All clients files were found to be complete. One of the staff files were found to be incomplete, lacked fingerprint clearance and was not associated to the facility. During the visit, LPA Campbell found that the staff person had an incomplete application.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil penalties.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 02:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: YANNICA GUEST HOME	FACILITY NUMBER: 392700729
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a record review of all 5 staff files,, the licensee did not comply with the section cited above as observed by LPA Campell in 1 out of 5 staff files reviewed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Effective Immediately, but no later than 11/15/2024; the licensee shall remove S1 from the facility and have the employee fingerprinted prior to returning to work. A Civil penalty is being issued in the amount of $500 because S1 has been working since 2023 and has not been fingerprinted. Licensee shall send proof of completion to be sent to CCLD by POC date at renee.campbell@dss.ca.gov

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.

Lisa Rios	TELEPHONE: (916) 969-9685
Renee Campbell	TELEPHONE: (916) 206-6380
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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