392701196-9-26-2023-27-AS-APAA-CW33YC-20230926183942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701196
Report Date: 09/26/2023
Date Signed: 09/26/2023 06:39:54 PM

Document Has Been Signed on 09/26/2023 06:39 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:	D & T GUEST HOME		FACILITY NUMBER:	392701196
ADMINISTRATOR:	HAIDER, MONESA		FACILITY TYPE:	740
ADDRESS:	2519 NEPTUNE CT		TELEPHONE:	(510) 299-5561
CITY:	TRACY	STATE: CA	ZIP CODE:	95304
CAPACITY:	6	CENSUS: 4	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Monesa Haider		TIME COMPLETED:	03:30 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 09/26/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unnanounced to conducted an annual visit. LPA met with Facility Designated Administrator, Monesa Haider and explained the purpose of the visit. There was one other staff member present at the facility, Claudia Castaneda and Abdul Haider. The administrator certificate for Administrator, Monesa Haider is active and expires on 07/27/2023. However, the administrator has sent in the required documentation by the expiration date and is awaiting for renewal by the department. This facility is licensed to serve 6 elderly residents, 2 can be deemed bedridden, and 3 can be deemed non-ambulatory. A brief interview with Monesa Haider. Current census was 4. 1 out 4 residents were out of the facility at this time. LPA reviewed 4 resident files and 3 staff files. All files were current and complete. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible. Fire extinguishers were purchased on 07/24/2023. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. A tour of 4 resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time. A review 3 resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. It was observed that one faucet was measured to be at 140 degrees.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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: D & T GUEST HOME	FACILITY NUMBER: 392701196
	VISIT DATE: 09/26/2023

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First aid kit was observed to be present and contained all of the required components at this time.
A tour of the laundry room was conducted. LPA observed toxins and laundry detergent to be made inaccessible at this time.
A review of the medication was conducted. Along with the Facility Designated Administrator, medication was reviewed and compared to the medication dispensing logs.
A tour of the backyard was conducted. Perimeter fence and gate was observed to be in good repair. Backyard had no hazards present.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

A technical violation was provided for 87303(e)(3).

No deficiencies found during this annual visit. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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