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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701033
Report Date: 06/05/2023
Date Signed: 06/06/2023 03:32:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/06/2023 03:32 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: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: 5DATE:
06/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Olivia KelleyTIME COMPLETED:
02:30 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. 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 134 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.

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 able to reviewed resident or staff files. During the file review LPA observed an outdated LIC 602 for R1. Also observed was the expired CPR first aid for S1. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Fire drill was conducted on 5/13/2023.

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: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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 3


Document Has Been Signed on 06/06/2023 03:32 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
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: 06/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
CCR
87303(e)(2)

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(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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The Facility will lower hot water heater today and test the hot water for 3 days. Please send hot water temperature reading to LPA.
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Hot water temperature was measured at 134.5 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.
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Type B
06/19/2023
Section Cited
CCR87705(c)(5)

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Care of Persons with Dementia
Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.
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All residents diagnosed with dementia will be scheduled with their physician and be assessed for any changes to their needs with an updated LIC 602.
Please send updated LIC 602 by POC date
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 LPA observed that R1 diagnosed with dementia didn't have an updated LIC 602
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/06/2023 03:32 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
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: 06/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
HSC
1569.618(c)(3)

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(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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Licensee/Administrator shall have S1 obtain re-certification in First Aid/CPR and provide documentation to CCL by fax by 6/6/2023.
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This requirement is not met as evidenced by: LPA observed outdated First Aid/CPR for S1. This poses a risk to residents in care.
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The facility will have a staff with a current first /aid cpr card today 6/5/2023

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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
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