392700729-4-25-2025-27-AS-NWPN-DG3U92-20250425152224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700729
Report Date: 04/25/2025
Date Signed: 04/25/2025 03:22:32 PM

Document Has Been Signed on 04/25/2025 03:22 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:	04/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Margie Cabalo		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 4/25/25, at 1:30 the Licensing Program Analysts(LPAs) Noel Wolf Petersen and Michael Bilger arrived unnannounced to the facility, to perform an annual inspection. They met with licensee Maxima Martin, and explained the purpose of the visit. This facility is licensed as a Residential Care Facility for Elderly adults a capacity of 6 and a current census of 6. There are zero (0) on oxigen administration, one (1) that is bedridden, four (4) that were on hospice, four (4) that have dementia, and two (2) that are utilizing home health care worker services. The facility Physical Plant was inspected, including but not limited to the kitchen, storage areas, exterior, recreation common area, hallways, resident bedrooms and resident bathrooms. No bodies of water were observed. The required posters were displayed including the ombudsman, federal work poster, and the rights poster. The bedrooms had the required furnishings, and lighting was observed on the way to the bathroom. The premises including the fire exits were free of obstruction. The physical plant is clean and in good repair. The first aid kit was inspected and found to have all the required items, the fire extinguisher was dated 1/2/25 and the resident water temperature measured in the bathroom was within the 105-120*F range per regulation. 2 days of perishable food was observed, 7 days of non-perishable food was observed and in compliance with regulation. Sharps and toxics were locked and stored away from food, inaccessible to residents. The medication storage was locked. Fire alarm was in working order, and fire drills are up to date through last quarter. Phones are in working order and clients have the capacity to take private calls. Continued on C page.

Liza King	TELEPHONE: (650) 676-0442
Noel Wolf Petersen	TELEPHONE: (916) 263-4700
	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/25/2025

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The staff records and client records were requested for review, the admission agreement, training documents, plan of operation, infection control plan, first aid documentation, fingerprint clearance for background checks, were found to be complete and in compliance. The client's needs and services plans that designated particular forms of care were met to specification outlined in the documents.

An exit interview was conducted with the Licensee and the copy of the report was read and given to the staff.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Noel Wolf Petersen	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC809 (FAS) - (06/04)

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