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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700979
Report Date: 12/28/2021
Date Signed: 12/28/2021 02:29:26 PM

Document Has Been Signed on 12/28/2021 02:29 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:ESTEEMED RESIDENTIAL CAREFACILITY NUMBER:
392700979
ADMINISTRATOR:WALTERS, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:9109 BLUE GRASS DRTELEPHONE:
(925) 219-2787
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 1DATE:
12/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Christopher WaltersTIME COMPLETED:
02:45 PM
NARRATIVE
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On 12-28-21 at 1:16pm, Licensing Program Manager (LPA) Michael Bilger arrived unannounced to conduct a case management visit for a reported incident occurring on 11-19-21. LPA met with Administrator Christopher Walters and explained the purpose of the visit. LPA reviewed record for Resident1 (R1) and interviewed administrator. Based on record review and interview. It was determined that on 11/19/21 at approximately 11:15pm R1 became physically and verbally aggressive towards staff, and exited facility. Staff followed R1 and notified police department for assistance. R1 returned to facility with staff supervision at approximately 1:30am. Administrator reported incident to regional department on 11/20/21. Based on additional record review and interview, it was determined that a client medical assessment for R1 to determine appropriateness for facility placement was not completed prior to R1's admission on 11/14/21. Based on today's visit deficiencies are cited under Title 22, division 6.

An exit interview was conducted with Administrator Christopher Walters and a copy of this report was left with Christopher. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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 12/28/2021 02:29 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/28/2021 at 02:07 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: ESTEEMED RESIDENTIAL CARE
FACILITY NUMBER: 392700979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2022
Section Cited
CCR
80069(b)(e)

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Client medical assessment. (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (e) The licensing agency shall have the authority to require the licensee to obtain a current written medical assessment...to verifiy the appropriateness of a client's placement.
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Licensee will complete physician's report for R1 and submit completed document to LPA by POC due date.

Licensee will submit a plan to ensure physician reports are obtained for all future clients prior to admission. Plan to be submitted to LPA by POC due date.
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This requirement is not met as evidenced by: Based on record review and interview, Licensee did not ensure the completion of a physician's report for R1 necessary to determine appropriate placement into facility, which poses a potential health and safety risk to resident is care.
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Licensee will read regulation 80069(b) and submit a signed statement to LPA by POC due date.

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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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