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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701217
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:56:05 PM

Document Has Been Signed on 06/14/2023 01:56 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:EUCLID RESIDENTIAL CAREFACILITY NUMBER:
392701217
ADMINISTRATOR:ASUNCION, TROPYFACILITY TYPE:
735
ADDRESS:2429 W EUCLID AVETELEPHONE:
(209) 915-1713
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 4CENSUS: 4DATE:
06/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tropy AsuncionTIME COMPLETED:
02:05 PM
NARRATIVE
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On at 6-14-23 at 10:15am Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct a post-licensing visit. LPA met with the administrator Tropy Asuncion and explained the purpose of the visit.

LPA 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 of the facility to ensure compliance with Title 22 regulations. Facility is a 4-bed adult residential facility with a current census of 4. Facility has 4 bedrooms and 2 bathrooms for resident use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 1 ambulatory residents, 3 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved COVID Mitigation plan LIC 808 form in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 71*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2-22-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medication records were reviewed and it was determined that various medications were not given as ordered for 3 of 4 clients in care as indicated on medication log sheets dated May 2023 and June 2023. First aid kit was observed to have adequate supplies and accessible to staff.
During this inspection 4 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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: EUCLID RESIDENTIAL CARE
FACILITY NUMBER: 392701217
VISIT DATE: 06/14/2023
NARRATIVE
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LPA completed 2 resident interviews and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA's record review revealed no evidence of quarterly fire drills conducted since licensure on 2-1-23. Facility has 1 resident with bedrails with physician orders in place. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit as noted on LIC 809D. Exit interview was held and a report was given to Administrator Tropy Asuncion. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2023 01:56 PM - It Cannot Be Edited


Created By: Michael Bilger On 06/14/2023 at 12:46 PM
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: EUCLID RESIDENTIAL CARE
FACILITY NUMBER: 392701217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 3 of 4 client record reviewed. Licensee did not ensure multiple medication given to 3 of 4 clients in care during the months of May and June of 2023, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee will ensure completed staff training on medication delivery and medication records. Licensee to submit training date to LPA by POC due date. Proof of completed training to be submitted to LPA, and training to be completed no later than 2 weeks from date of citation issuance.
Licensee to submit a plan to audit medication records to ensure accuracy and delivery of medications to clients in care. Plan to be submitted to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/14/2023 01:56 PM - It Cannot Be Edited


Created By: Michael Bilger On 06/14/2023 at 12:46 PM
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: EUCLID RESIDENTIAL CARE
FACILITY NUMBER: 392701217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee did not maintain evidence of quarterly fire drills since licensure on 2-1-23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee will complete current fire drills and submit proof of completion to LPA by POC due date.
Licensee will read Health and Safety Code 1565(c) and submit a signed declaration of understanding to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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