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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701051
Report Date: 09/10/2024
Date Signed: 09/11/2024 08:01:05 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2024 08:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BEAVERS RESIDENTIAL CARE HOMEFACILITY NUMBER:
392701051
ADMINISTRATOR/
DIRECTOR:		ZENO-BEAVERS, MONICAFACILITY TYPE:
735
ADDRESS:5137 SHIPWHEEL DRIVETELEPHONE:
(209) 594-0590
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 0DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Tina MalveauxTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 09/10/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua met with Tina Malveaux and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. LPA was informed that the Facility Designated Administrator (FDA), Monica Zeno-Beavers was not able to attend this annual visit at this time. LPA continued the visit with Tina Malveaux.
It was learned that this facility is awaiting Vendorization from Valley Mountain Regional Center. This facility is licensed to serve and retain residents from the ages of 18-59 who are ambulatory only. Current Census 0.
The following Technical Assistance was provided during today's inspection. These concerns must be addressed and Licensing must be contacted for an additional inspection prior to the admittance of any residents.
If Licensing is not informed, and the inspection is not completed prior to admitting any residents into care, Administrative Actions may be taken.
  • All toxins shall be locked and inaccessible to residents in care.
  • Fire extinguishers must be serviced to date within annual inspection date.
  • The Licensee will submit the documentation of any staff to be associated to this facility.
  • There shall be a designated space for personal items, for example, a change of clothes, handbags, coats, meals, medications, etc. Personal items shall not be stored in multiple bedrooms, drawers, or closets.
  • All prescription medications shall be locked and inaccessible to residents in care. Expiration dates shall be checked periodically and disposed appropriately.
  • The Licensee shall remove the dried vegetation and weeds.
  • All exit gates must be free of any obstructions
  • All food items in the refrigerator, freezer, and pantry will be inspected and all expired items shall be disposed.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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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: BEAVERS RESIDENTIAL CARE HOME
FACILITY NUMBER: 392701051
VISIT DATE: 09/10/2024
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It was learned during the course of this visit that S1 was not transferred and associated to this facility. Due to S1 not being associated to the facility a civil penalty of $100 was provided today for violation of 80019(e)(4).

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to the facility. An exit interview was held, and a copy of the report was provided in-person.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2024 08:01 AM - It Cannot Be Edited


Created By: Arielle Pascua On 09/10/2024 at 10:47 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEAVERS RESIDENTIAL CARE HOME
FACILITY NUMBER: 392701051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
80019(e)(4)

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(4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility. This is not met as evidenced by:
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Licensee shall associate and transfer S1 to the facility by POC date. A statement of correction shall provided to the LPA by POC date.
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Based on facility records, it as observed that S1 was not associated to the facility. It was learned that S1 was residing at this facility in the staff bedroom. This poses an immediate health, safety, and personal rights risks to persons in care.
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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 Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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