392701060-9-24-2021-27-AS-MBIR-C76W4M-20210924165746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701060
Report Date: 09/24/2021
Date Signed: 09/24/2021 04:57:51 PM

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:	SV RESIDENTIAL FACILITY 2		FACILITY NUMBER:	392701060
ADMINISTRATOR:	YADAO, VIRGINIA ARRUBIO		FACILITY TYPE:	740
ADDRESS:	516 TULE SPRING STREET		TELEPHONE:	(209) 915-9955
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	4	CENSUS:	DATE:	09/24/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Virginia Yadao		TIME COMPLETED:	05:03 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) Michael Bilger conducted an announced pre-licensing visit to this facility on 9/24/21 at 1:32pm and was met by the Applicant, Virginia Yadao. Brief interview was conducted with applicant It was learned that this facility will be licensed as an Residential Care Facility for the Elderly (RCFE) to serve up to 4 non-ambulatory clients .This Applicant is also seeking vendorization from local regional center to accept and retain Level 4I clients. There were no clients present during today's pre-licensing visit. Tour of the facility was conducted. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. COVID Precautions in place including signage, PPE storage and 30-day supply were observed. Isolation rooms designated. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguisher in place at dining area near kitchen and fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster was observed. Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. All appropriate locks in place to secure sharp objects and toxins. Food supply for 2-day perishable and 7-day non-perishable quantities were reviewed to ensure this facility was in compliance at this time. There is an upstairs area for staff use only and secure. Medication cabinet, located in the kitchen area, was observed and securely locked. First aid kit was observed to be present and contained all required components at this time. Garage access was noted with locking cabinets in place securing all toxins and other dangerous materials. A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. {Cont. on LIC 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SV RESIDENTIAL FACILITY 2	FACILITY NUMBER: 392701060
	VISIT DATE: 09/24/2021

NARRATIVE

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A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured at 113.1*F which is within the allowed range of 105-120 *F.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time.

This facility has been found to be in compliance at this time.
There were no deficiencies observed during today's Pre-licensing visit. Component III completed with applicant during visit. Mitigation plan was received and approved during visit. Exit Interview conducted with Virginia Yadao A copy of this report was left with the Applicant.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

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