392700768-7-3-2025-27-AS-NWPN-DJ8RU4-20250703131918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700768
Report Date: 07/03/2025
Date Signed: 07/03/2025 01:19:24 PM

Document Has Been Signed on 07/03/2025 01:19 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:	LEAFE RESIDENTIAL HOME		FACILITY NUMBER:	392700768
ADMINISTRATOR/ DIRECTOR:	RAQUENO, MELISSA		FACILITY TYPE:	735
ADDRESS:	1330 LEVER BLVD		TELEPHONE:	(209) 944-5925
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 4		CENSUS: 2	DATE:	07/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Melissa Raqueno		TIME VISIT/ INSPECTION COMPLETED:	01:30 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 7/3/25 at 10am licensing program analyst (LPA )Noel Wolf Petersen arrived unannounced to Leafe Residential Home and met with administrator Melissa Raqueno to explain the purpose of the visit: to conduct an annual inspection. The home is an ARF with 2 residents and a capacity of 4, both residents are ambulatory, and have no restricted conditions. The physical plant was inspected, including but not limited to the kitchen, storage areas, common areas, exteriors, evacuation routes, client bathrooms, and client bedrooms. The facility is clean and the traffic areas are well lit and unobstructed. Toxics and sharps and medications are stored locked and away from residents in care. the food supply includes 2 days of perishable and 7 days on nonperishable food. two(2) client MARs were checked and the medications and documentation were found to be in agreement as to kind and quantity. the common area has furnishings in good repair and varied set of activities with equipment in good repair. the exterior has appropriate space for outdoor activities, furnishings and evacuation route exit are in good repair. The bathroom hardware is in good repair and had its water temperature measured within the required 105-120*F. Bedroom required furniture elements were in good repair, LPA mentioned the inclusion of encasements to proactively prevent recurant infections and pest activity. the Administrator provided that the beds would be equipped with them. The linen is in good supply. First aid kit has all required items, the fire extinquisher was last checked 5/29/25, and the required posters are present except the federal work requirements poster. The administrator provided that one would be obtained and posted. The carbon monoxide and Smoke alarms are functional. Continued on C page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

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: LEAFE RESIDENTIAL HOME	FACILITY NUMBER: 392700768
	VISIT DATE: 07/03/2025

NARRATIVE

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a review of administrator records was conducted, including the administrator certificate, facility license, facility sketch, Program design, admission agreement, surety bond, liability insurance, and the shift log. Documents were found to be up to date and in compliance.

1 staff interview was conducted. 3 staff records were reviewed, including but not limited to, criminal record and medical clearance, first aid and continuing training, as well as guardian association. Documents were found to be up to date and in compliance.

No client interviews were conducted, as they are at program. 2 client records were reviewed, including but not limited to the ipp, signed admission agreement with policy amendums, cash resources, the preappraisal and recent health screenings. Documents were found to be up to date and in compliance.

Per title 22, no citations were issued, as part of this visit. no appeal rights were provided.

An exit interview was conducted, a copy of the report was read and given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC809 (FAS) - (06/04)

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