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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:14:31 PM


Document Has Been Signed on 07/29/2024 04:14 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 48DATE:
07/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Greg AwreyTIME COMPLETED:
04:30 PM
NARRATIVE
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On /7/29/2024, LPA Johnson arrived unannounced to conduct a case management visit into an incident report received on 7/26/2024.

The incident detailed that a Resident found a bottle of cleaning solution in the bathroom of his apartment. R1 drank half of the cleaning solution when staff intervened. He said he did it because “it was a good way out.” Poison control was called and he was transported to St. Joseph emergency room and R1 is presently being care for there.

LPA reviewed resident file and obtained copies of relative information. R1 Physician's report confirmed that R1 is able to maintain his grooming and hygiene items. R1 discharge summary from St. Joseph's Behavioral health dated 2/9/2024 confirmed that R1 presented to the emergency room with suicidal Ideations and severe depression.

LPA advised the facility to report all incident to the department and to provide the required information to confirm a new Administrator.

Deficiencies were cited on the attached 809 D page. At the time of the visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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 07/29/2024 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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The facility will assess residents discharge summaries for information that may have been missed.

The Administrator and RCD will provide the department with a plan
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Based on observation the licensee failed to secure toxins. A cabinet in a resident bathroom contained toxins. R1 took the toxin and ingested the cleaning supplies. This poses an immediate health and safety risk to residents in care.
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to review discharge paper work prior to admissions.

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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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