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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700787
Report Date: 03/30/2022
Date Signed: 04/20/2022 09:43:34 AM

Document Has Been Signed on 04/20/2022 09:43 AM - 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:LIBBIE CARE HOMEFACILITY NUMBER:
392700787
ADMINISTRATOR:RAM, AVINESHFACILITY TYPE:
735
ADDRESS:558 E EDISON STTELEPHONE:
(209) 824-5993
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 5CENSUS: 3DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Avinesh RamTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 03/30/2022 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Avinesh Ram, who was requested by this LPA to go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. It was learned that Mr. Ram is also a designated Administrator for this facility as well. A review of his Administrator certificate was conducted.
This facility accepts and retains up to 5 residents at any given time, of which only (5) are ambulatory only.
Current census was 3 residents.
Tour of this facility was conducted.
Kitchen area was toured. Food storage units were reviewed for 2-day perishable and 7-day nonperishable food quantities Additional food supplies were observed to be present in the garage area with exterior storage units. Freezer unit and additional nonperishable food quantities were present and observed at this time.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 02/17/2021 by the local fire extinguisher company, Alpha Fire Control, at this time.
Laundry area, located in the garage area, was toured. It was learned that residents are encouraged to do their own laundry and request for assistance if needed.
Medication cabinet, located in the dining area, was reviewed. It was observed to be locked and made inaccessible to the residents at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LIBBIE CARE HOME
FACILITY NUMBER: 392700787
VISIT DATE: 03/30/2022
NARRATIVE
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Linen closet was reviewed and observed to contain a sufficient supply of towels, sheets, and linens to be able to meet the needs of the residents at this time.
The facility perimeter fence, side gates, and exits were reviewed at this time.

The following forms and documents were requested to be updated and submitted into CCL:
  1. LIC 308
  3. LIC 400
  5. LIC 500
  7. LIC 610

The following deficiencies were observed and cited on the LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

A civil penalty in the amount of $100 was issued on the LIC 421 BG for lack of proper fingerprint trransfer of a facility staff person.

The appeal rights were printed and a copy was given to the facility representative at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/20/2022 09:43 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/30/2022 at 12:15 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: LIBBIE CARE HOME
FACILITY NUMBER: 392700787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [2] persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Facility representative stated that proof of the transfer clearance will be completed and submitted into CCL for review by this LPA by the due date of 03/31/2022.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/20/2022 09:43 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/30/2022 at 12:15 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: LIBBIE CARE HOME
FACILITY NUMBER: 392700787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in review of the backyard area, and its
walkways, needed to be cleared and cleaned to remove weeds and unused items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2022
Plan of Correction
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Facility representative stated the backyard area will be cleaned and cleared of any weeds and unused items so that all walkways and paths are kept free and clear at all times. A statement of correction, with photos of cleaned and cleared backyard area, to be completed and submitted into CCL by the due date of 04/06/2022.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
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