392700932-9-2-2025-27-AS-NWPN-DL5RW4-20250902132232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700932
Report Date: 08/27/2025
Date Signed: 09/02/2025 01:23:58 PM

Document Has Been Signed on 09/02/2025 01:23 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:	BUENA VIDA CARE HOME II		FACILITY NUMBER:	392700932
ADMINISTRATOR/ DIRECTOR:	LADION, PIERRE J.		FACILITY TYPE:	735
ADDRESS:	1143 LUNA LANE		TELEPHONE:	(209) 464-1668
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 4		CENSUS: 3	DATE:	08/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Pierre Laidon		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	Licensing Program Analyst(LPA) Noel Wolf Petersen, arrived unannounced to conduct an annual inspection, the LPA met with administrator/licensee Pierre Laidon and Staff. The LPA explained the purpose of the visit, Buena vida Care home 2 is a level 2 ARF with a capacity of 4 and a current census of 3. the facility have one resident over 60, a waiver for age exists for the facility because at one point they were over 60 with 2 people. Administrator will send the LPA a copy of the waiver. Physical Plant was inspected, including but not limited to the kitchen, common areas, storage areas, resident bedrooms, resident bathrooms, the exteriors, and the evacuation routes. The facility has a bug/spider problem in the bathroom/garage/exterior, administrator addressed the areas with a manual scrubber durring the inspection. The facility will have a strict compliance to the regulation addressing insect/pest infestation in the future. The Kitchen has adequate storage for sharps and toxics, common areas are clean, resident bedrooms have required furniture. Administrator mentioned having bedbug incasements ready to install, to be installed at the earliest time possible. The bathroom hardware is functional, water is within compliant 105-120*F. the exteriors have space for activities, the exit gate is still swinging freely and self latching, but gravity has begun to take a toll and is in need for periodic maintenance. MARS and Medications were up to date and in agreement with quantity and kind for 2 residents at random. The Posters were of the correct size and kind, the fire extinguisher was date 2/11/2025, No bodies of water exist. Continued on c Page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

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: BUENA VIDA CARE HOME II	FACILITY NUMBER: 392700932
	VISIT DATE: 08/27/2025

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Administrator certificate was out of date, Administrator provided three classes were not approved dispite being from an authorized vendor(understanding depression and suicide in older adults, ce and diabedes in overview, medication management of heart disease). LPA gave the guidance to get another vendor and send in the 3 credits of class certificates when competed.

Administrator documents were reviewed. evacuation plan needed a second location, (LIC 610e) to be sent to the lpa, Infection control plan was not present and the facility a copy needs to be sent to the lPA. Other documents, Fire clearance, surety bond, facility license, facility sketch, and liability insurance were present and up to date.

Client files had most of the required documents: Medical preappraisal, IPP plans, present and up to date. 1 of 3 reviewed needed a signed admission agreement. Once signed by the person/authorized representative, the licensee, and VRMC, it should be sent to the LPA.

Staff files had Most of the required documents: continuing training, fingerprint clearance, backround checks present and up to date. 1 of 2 reviewed needed a first aid/cpr certficate renewed(three months expired). LPA advised that staff cannot work a shift without someone having a firstaid/cpr card present in the building. Staffing is low, for the event of an emergency response or a sick call out there would be a concern about care and supervision, Administrator provided it is a level 2 home with high functioning adults and they have other staff they can use in such an event at the other facility(buena vista 1), LPA is asking for any on call staff to have a staff binder here, be associated to the facility via gaurdian, and added to the LIC500 as "on call" and then turn the Lic500 to the LPA.

No citations issued at this time. the LPA is expecting the requested docutments and/or proof of fixes to be sent in by 9/27/25.

A copy of the report was read and left with the administrator.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC809 (FAS) - (06/04)

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