<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701033
Report Date: 06/23/2022
Date Signed: 06/28/2022 10:58:05 AM


Document Has Been Signed on 06/28/2022 10:58 AM - 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:ST. RITA CARE HOMEFACILITY NUMBER:
392701033
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:3478 LADD TRACT CT.TELEPHONE:
(650) 465-2526
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 3DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:StaffTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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. 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 110 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the tour LPA and staff observed cleaning supplies on the counter in the main bathroom.

Fire extinguishers and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA was unable to reviewed resident or staff files they were locked in the garage and the key was not at the facility. The licensee will bring the files, both staff (2) and residents files to the office located at 2525 Natomas Park Suite 270, Sacramento, CA 95833 on 6/28/2022 at 1:30pm. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/28/2022 10:58 AM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ST. RITA CARE HOME
FACILITY NUMBER: 392701033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited

1
2
3
4
5
6
7
Personnel Records
All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LPA was unable to review facility records.
Based on confirmation of the Administrator records were unavailable for review.
This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
06/24/2022
Section Cited

1
2
3
4
5
6
7
Storage Space. 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
8
9
10
11
12
13
14
Licensee failed to ensure the regulations were met based on observation during the tour LPA and staff observed cleaning supplies on the counter in the main bathroom.
8
9
10
11
12
13
14
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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2