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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700932
Report Date: 06/19/2023
Date Signed: 06/19/2023 01:03:14 PM

Document Has Been Signed on 06/19/2023 01:03 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: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:
06/19/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Benilda MedranoTIME COMPLETED:
12:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Benilda Medrano and explained the purpose of the visit. Administrator Certificate expires on 6/26/23.

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 5/2023. 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 2 staff files, including criminal record clearances. During the file review for Staff, LPA did not observed a health screening for S1 including a TB test.

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: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 06/19/2023 01:03 PM - It Cannot Be Edited


Created By: Albert Johnson On 06/19/2023 at 11:34 AM
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: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2023
Section Cited
CCR
87411(f)

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General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment.
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Administrator to provide a health screening/TB results for staff (S1) by POC date 6/20/2023
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LPA observed staff did not have a health screening and TB test results in S1's file.
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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: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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