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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700893
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:49:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/05/2022 04:49 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:SHADMAN HOUSEFACILITY NUMBER:
392700893
ADMINISTRATOR:SHADMAN, KIRSTENFACILITY TYPE:
735
ADDRESS:3832 CHERRYLAND AVETELEPHONE:
(209) 451-4595
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 5CENSUS: 5DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Amanda JacobsTIME COMPLETED:
05:00 PM
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On 12/5/22 at 2:40pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Amanda Jacobs and explained the purpose of today's visit. Amanda holds current Administrator certificate # 6051897735 which is good through 10/21/23.

LPA Jensen toured the grounds and physical plant. There is a single designated entrance equipped for COVID screening. There is a sign in log at the entrance, a wall thermometer for temperature screening, sanitizer and PPE available.

All required signs were posted in prominent locations in the facility including but not limited to infection control, personal rights, employee rights, see something-say something, facility sketch and emergency disaster plan.

The facility was observed to be sanitary and free of odor. There are 5 single occupancy bedrooms. Each bedroom was furnished with a dresser, night stand, lamp and chair. The facility maintains an adequate supply of linen and bedding. The bathrooms were observed to be equipped with grab bars and non-slip mats in the shower. The water temperature in the bathroom main hall was measured at 111.6 degrees which falls within the required regulatory range of 105-120 degrees. The water heater is equipped with a regulator that does not allow the water to heat above 120 degrees. The thermostat was set at 72 degrees for the comfort of the residents. LPA Jensen observed emergency lighting to be available in the facility and the hallways were equipped with night lights leading to the bathroom. All toxins and cleaning supplies were observed to be locked and inaccessible to residents in care.

The fire extinguisher was last serviced in March of 2023 and is in compliance. The carbon monoxide detector was tested and observed to be in good working order.
Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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: SHADMAN HOUSE
FACILITY NUMBER: 392700893
VISIT DATE: 12/05/2022
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The kitchen was observed to have in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. All food that is removed from the original packaging is labeled and dated. There was no expired food in the facility. An emergency supply of food and water is maintained. The first aid kit was observed to be complete with scissors, tweezers, a thermometer, manual and various wound dressings. All knives and sharp objects were observed to be locked and inaccessible to residents in care.

There were 4 staff members present at the facility. All staff members were verified to be fingerprint cleared and associated to the facility. LPA Jensen reviewed the staff files of all 4 staff members that were present and found them to be organized and complete with all required documentation. LPA Jensen reviewed 5 of 5 client files and determined them to be complete. LPA Jensen reviewed the Medication Administration Record (MAR) for one client and verified the MAR against the medication and found all records to be accurate. The medication room is locked at all times. There are no narcotics currently stored at the facility.

The grounds were observed to be well maintained and all paths were observed to be free of obstruction. There are numerous activities available for the residents for both indoors and outdoors.

The facility has been determined to be in substantial compliance.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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