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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700747
Report Date: 02/17/2022
Date Signed: 05/18/2022 02:43:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/18/2022 02:43 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: 1DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Josie VeaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Josie Vea and explained the purpose of the visit. There is one residents in care at this time.

LPA inspected the physical plant. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 106 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 unlocked in residents room. There is no Physician's report in residents file and the Individual Program Plan is expired as of 2/2021.

First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

Deficiencies were observed and cited on the attached 809D page. Advisories given for resident and staff files.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
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)
Page: 1 of 2
Document Has Been Signed on 05/18/2022 02:43 PM - It Cannot Be Edited


Created By: Albert Johnson On 02/17/2022 at 11:21 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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
80070(b)(8)

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80070(b)(8) Client Records. Each client record shall contain a medical assessment which includes ambulatory status.

This requirements not met based on record review.
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Administrator will provide for R1 a physician's report (LIC 602) by 2/18/22 or make arrangments for this to be completed.
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R1 does not have a physician's report (LIC 602). This poses a potential health and safety risk to client.
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Type A
02/18/2022
Section Cited
CCR80075(k)(1)

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Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator will ensure training is conducted with staff to ensure all medications are locked after every use. Administrator will submit proof of traing to CCL by 2/18/2022
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LPA observed unlocked medications in residents room.
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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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
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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