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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700747
Report Date: 04/02/2024
Date Signed: 04/02/2024 12:41:35 PM

Document Has Been Signed on 04/02/2024 12:41 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:VEA'S CARE HOMEFACILITY NUMBER:
392700747
ADMINISTRATOR:FHARELL, MICHAELFACILITY TYPE:
735
ADDRESS:2232 S SACRAMENTO STTELEPHONE:
(209) 662-5783
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Josie Vera - Direct Care StaffTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted a unannounced Required 1 year Inspection Visit. LPA met with direct care staff and explained the purpose of visit. Administrator's Certificate expires 7/27/2024.

LPA and direct care staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, and outside backyard. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 113.4 degrees Fahrenheit which is within the required range of 105 to 120 degrees. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

Fire extinguisher last inspected on 2/23/2023 and is expired. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 2/2/2024. Staff have been sleeping on a roll away bed in common area or garage which is not on fire clearance.

LPA reviewed four resident files and three staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA requested the following updated documents for community care licensing to be submitted via email by April 5, 2024: Facility Sketch, Fire Clearance, LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Surety Bond. ruth.wallace@dss.ca.gov
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, see 809-D's for deficiencies observed or cited today. If the deficiencies are not corrected by the noted due date civil penalties may be assessed.

Exit interview conducted with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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Document Has Been Signed on 04/02/2024 12:41 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/02/2024 at 11:34 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: VEA'S CARE HOME
FACILITY NUMBER: 392700747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in fire extinguisher expired on 2/23/2024 and staff are sleeping on roll away bed in common areas which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Licensee agrees to submit a plan of correction by 4/3/2024 stating how staff will not sleep in common areas according to fire clearance. Licensee purchased new fire extinguisher on 4/2/2024 to replace expired fire extinguisher. Immediate civil penalty of $500.00 was issued on 4/2/2024. Submit via email to LPA. ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2024 12:41 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/02/2024 at 12:27 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: VEA'S CARE HOME
FACILITY NUMBER: 392700747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80064(a)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in licensee did not request the City of Stockton for permits to complete or convert the garage into a staff room on 5/4/23 per LPA visit. LPA informed the staff that the permits along with a LIC 200 form with a new fire clearance inspection will be required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Licensee agrees to submit a plan of correction stating how permits to complete or convert garage into a staff room will be completed. If licensee is not going to convert garage into staff room, a plan needs to state what licensee agrees to do for staff arrangements. Submit via email to LPA. ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


LIC809 (FAS) - (06/04)
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