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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700981
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:09:55 PM

Document Has Been Signed on 02/24/2023 12:09 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:PHOENIX HOUSE ARF, INCFACILITY NUMBER:
392700981
ADMINISTRATOR:CAMPBELL, SCOTTFACILITY TYPE:
735
ADDRESS:2428 WARLOW LANETELEPHONE:
(209) 351-4808
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 5CENSUS: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bolden, RTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff 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. During the tour of the facility LPA observed two unlocked cabinets with toxin in both areas. The first was in the laundry room and the second was in the staff bathroom that was unlocked and residents had access to the unlocked cabinet under the sink. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 115 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. During the resident file review LPA observed that the P&I count was off for three residents. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Fire extinguishers and smoke detectors are operational. Fire drill was conducted on 2/16/23

Per the Title 22, Division 6 of California Code of Regulations, Deficiencies were observed during today's inspection.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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 02/24/2023 12:09 PM - It Cannot Be Edited


Created By: Albert Johnson On 02/24/2023 at 11:41 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: PHOENIX HOUSE ARF, INC
FACILITY NUMBER: 392700981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited
CCR
80087(g)

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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible.
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Facility shall ensure that toxins are kept locked and inaccessible to all clients in care. Facility shall conduct an in-service and submit a plan on how the facility shall ensure that all toxins are kept locked. POC shall be submitted to Licensing by 2/24/23. Toxins were locked during the inspection
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 LPA and staff observed toxins unlocked in the lanudry area and the unlocked staff bathroom by the residents activity table which is accessible to residents.
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Type B
03/10/2023
Section Cited
CCR80026(h)

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Safeguards for Cash Resources, Personal Property and Valuables. Each licensee shall maintain accurate records of accounts of client cash resources, personal property valuables entrusted to his/her care
-P & I ledger balance did not equal monies that were counted on hand for R1, R2 and R3.
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Administrator shall audit P & I ledgers/monies for all residents in care and submit proof of accurate accounts of residents cash resources to CCL by POC 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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