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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701156
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:29:44 PM

Document Has Been Signed on 08/02/2022 12:29 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:NANTUCKET RESIDENCE, THEFACILITY NUMBER:
392701156
ADMINISTRATOR:GESMUNDO, PAOLOFACILITY TYPE:
740
ADDRESS:3232 WISCONSIN AVETELEPHONE:
(209) 636-3456
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 6DATE:
08/02/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Orchid DamrichobTIME COMPLETED:
12:45 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
On 8-2-22 at 10:13am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a post licensing visit.. LPA was greeted by Administrator Orchid Damrichob and LPA explained the purpose of the visit. Upon entry, it was observed that Staff1 (S1) was not wearing a face mask. Additionally, based on interview, it was determined that Staff2 (S2) contracted COVID which has not yet been reported to Licensing department.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed residential care facility for the elderly with a current census of 6. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 3 bedrooms and 2 bathrooms. There is a formal living room and family/TV room for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted.
The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F.
Water temperature reads between 105*F and 120*F in the bathrooms and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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 5
Document Has Been Signed on 08/02/2022 12:29 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/02/2022 at 11:26 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)


Personal Rights of Residents in all facilities. (a)Residents in call residential care facilities for the elderly shall have all other following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, S1 was not wearing a mask while in the presence of resident in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
1
2
3
4
Licensee will read regulation 87468.1(a)(2) and submit a signed declaration of understanding to LPA by POC due date. Declaration to include understanding of mask requirement and signed by all staff.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/02/2022 12:29 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/02/2022 at 11:42 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(2)


Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports...(2)Occurences...which threaten the welfare, safety, or health of residents, personnel or visitors...within 24 hours either by telephone or facsimile to the licensing agency...This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview the licensee did not comply with the section cited above in that S2 contracted COVID-19 on 7/22/22 and not reported by licensee to licensing agency. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
1
2
3
4
Licensee will ensure reporting of all COVID cases of staff and residents to licensing agency per regulatory requirements by POC due date.

Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
VISIT DATE: 08/02/2022
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
26
27
28
29
30
31
32
The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguisher is fully charged and dated 2/11/22. Administrator certificate expires 2/28/2024.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on 809D. Exit interview was held and a report was given to Administrator Orchid Damrichob. Appeal Rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5