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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700979
Report Date: 10/04/2022
Date Signed: 10/04/2022 04:07:10 PM

Document Has Been Signed on 10/04/2022 04:07 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: 4DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Christopher WaltersTIME COMPLETED:
04:05 PM
NARRATIVE
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On 10-4-22 at 2:50pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 8-31-22. LPA met with Administrator Christopher Walters and explained the purpose of the visit. Administrator departed due to a previous engagement and gave permission for facility manager (S1) to sign in his absence. LPA reviewed incident report with facility manager and interviewed Administrator.

Based on interview and record review, it was determined that Resident1 (R1) eloped from facility on 8-31-22 at approximately 4:30pm. It was further determined that facility staff were aware of R1's departure from the front door and running down the street, but lost sight and supervision of R1 despite attempts to locate him. According to record review and interview, law enforcement was contacted at approximately 6:00pm on 8-31-22. Incident was further reported to licensing department, and to R1's service coordinator within appropriate regulatory time frame. R1 was located by facility staff on 9-4-22 and returned home.

As a result of today's case management, citations are issued under Title 22, Division 6. An immediate civil penalty was issued today in the amount of $500 due to violation of absence of supervision An exit interview was conducted with Christopher Walters and a copy of this report was left with Christopher. Appeal rights explained and to be emailed.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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 10/04/2022 04:07 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/04/2022 at 03:43 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: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
80078(a)

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Responsibility for providing care and supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee will read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.

Licensee submitted a plan to LPA describing new interventions in place to help ensure facility staff's knowledge R1's general whereabouts.
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Based on interviews and record reviews, R1 eloped from facility on 8-31-22 and facility staff was unaware of R1's whereabouts until approximately 6:00pm on 9-4-22 resulting in an absence of supervision. This poses an immediate health and safety risk to residents in care. A immediate civil penalty of $500 is issued in addition to citation.
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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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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