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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701156
Report Date: 04/04/2024
Date Signed: 04/04/2024 05:10:30 PM


Document Has Been Signed on 04/04/2024 05:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:NANTUCKET RESIDENCE, THEFACILITY NUMBER:
392701156
ADMINISTRATOR:CECIL DE LARAFACILITY TYPE:
740
ADDRESS:3232 WISCONSIN AVETELEPHONE:
(209) 636-3456
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 6DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cecil De LaraTIME COMPLETED:
03:16 PM
NARRATIVE
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On 4/4/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Administrator and explained the purpose of the visit.

The facility is a single story structure with wheelchair accessibility. LPA observed all required signage, including COVID related, to be prominently posted. LPA toured the facility indoors and outdoors including but not limited to dining room, living room, kitchen, garage, 2 bathrooms, 4 bedrooms and backyard. The facility is licensed for 6 clients.

Hot water temperature was measured at 130 degrees Fahrenheit in resident's bathroom sink, which is not within the required range of 105 to 120 degrees. Fire extinguishers are current and in compliance with fire safety. Fire drill was conducted on 3/1/2024. Carbon dioxide monitor present. LPA reviewed 6 resident and 2 staff files, including criminal record clearances. During the resident file review LPA observed that R1 has a prohibited health condition and will need to relocate. R1 moved into the facility on 3/29/2024. All staff today are associated to the facility. First aid kit was checked and is complete.

Deficiencies were cited as a result of today's visit. An exit interview was conducted and a report was left with the facility with appeal rights.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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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Document Has Been Signed on 04/04/2024 05:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
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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Administrator sent staff to purchase a temperature gun and again lowered the thermostat during the tour and agreed to test the hot water for 3 days.
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This requirements is not met as evidenced by Hot water temperature was measured at 130 degrees Fahrenheit in resident's bathroom sink. This is an immediate health and safety risk to residents in care.
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Test hot water in the bathroom to meet Title 22 regulations. Send 3 days hot water temperature to LPA.
Type A
04/05/2024
Section Cited
CCR87615(a)(4)

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
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Licensee/Administrator shall provide written proof of correction by close of business date of Proof of correction shall address the relocation of R1 and training deficiencies for administrator as well as licensee regarding prohibited health conditions.
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(4) Staphylococcus aureus ("staph") infection or other serious infection. this requirement is not met as evidenced by discharge papers. R1 has a diagnosis of carrier or suspected carrier of Methicillin resistant Staphylococcus
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Proof of correction to be sent to CCLD by POC date.
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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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