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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700932
Report Date: 06/16/2022
Date Signed: 06/17/2022 08:12:47 AM

Document Has Been Signed on 06/17/2022 08:12 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:BUENA VIDA CARE HOME IIFACILITY NUMBER:
392700932
ADMINISTRATOR:LADION, PIERRE J.FACILITY TYPE:
735
ADDRESS:1143 LUNA LANETELEPHONE:
(209) 464-1668
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Dardanela AllasTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with D. Allas and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies.

Fire extinguishers and smoke detectors are operational. Fire drill was conducted on 5/09/2022. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 3 staff files, including criminal record clearances. During the file review for Staff, LPA observed expired First aid cards for 2 of 3 Staff members reviewed.

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

Deficiencies were cited on the attached 809D page.

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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Document Has Been Signed on 06/17/2022 08:12 AM - It Cannot Be Edited


Created By: Albert Johnson On 06/16/2022 at 01:21 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: BUENA VIDA CARE HOME II
FACILITY NUMBER: 392700932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2022
Section Cited
CCR
85169(b)(2)

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Emergency Intervention Staff Training, Staff who use,
participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training.
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Licensee/Administrator shall ensure all staff have current first aid and CPR Certificates. By POC Date.
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This requirement is not met as evidenced by: Observation during file review the facility did not have current / valid First Aid - CPR Certificate for two staff.
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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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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