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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700997
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:02:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241030111610
FACILITY NAME:NOVELLUS STOCKTONFACILITY NUMBER:
392700997
ADMINISTRATOR:CHANTLLE HUDSONFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:LarryTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility does not ensure the heater is in good repair
INVESTIGATION FINDINGS:
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On 10/31/2024, LPA Johnson arrived unannounced to investigate the above allegation.

Based on interviews with staff on 10/31/2024, the facility is having issues with the (HVAC) heater. The parts to replace the heater have been received and the facility is actively working on fixing the heater. The facility has advised the residents of this matter and has offered to supply additional blankets and throws to comfort the residents while the heater is being repaired.

The allegation is substantiated meaning that there was a preponderance of evidence to prove that the allegation occurred as alleged.

An exit interview was conducted, a copy of the LIC9099, 9099-D, and appeals rights was provided to the Facility.

Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20241030111610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NOVELLUS STOCKTON
FACILITY NUMBER: 392700997
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
CCR
87303(a)(b-1)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.(b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).
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Licensee will repair the HVAC system to maintain a comfortable temperature by the POC date 11/1/2024. The facilities Staff will check each residents room to ensure that the residents are comfortable during the evening and will supply additional blankets or throws if needed.
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Based on an interview with the Staff the facility is having issues with the heater. The parts to replace the heater have been received and the facility is actively working on fixing the heater. This poses an immediate risk to the health safety of residents in care.
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The facility will send a report to the department by 11/1/2024 when the repairs have been completed.
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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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2