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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701217
Report Date: 07/28/2023
Date Signed: 07/28/2023 04:03:10 PM

Document Has Been Signed on 07/28/2023 04:03 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:
07/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Tropy AsuncionTIME COMPLETED:
04:15 PM
NARRATIVE
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On 7-28-23 at 2:21pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding physical environment. LPAs met with Administrator Tropy Asuncion and explained the purpose of the visit. LPAs conducted facility observation and interviewed Administrator. During facility tour, LPAs observed chemical closet in garage unlocked with chemicals accessible to residents in care. Additionally, LPAs observed a hammer in the garage accessible to residents in care. Additionally, LPAs observed evidence of mice presence in facility. Based on interview conducted, it was determined that mice presence was known longer than 1 week and incident was not reported to licensing within regulatory time frame, nor acted upon by Licensee in a timely manner for purposes of treating the incident and providing a safe, clean, and sanitary environment per regulatory requirements.

Based on today's case management, citations are issued under Title 22, Division 6 and noted on 809D. An exit interview was conducted with Tropy Asuncion and a copy of this report was left with Tropy. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 3
Document Has Been Signed on 07/28/2023 04:03 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/28/2023 at 02:39 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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2023
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements. (b) Upon the occurrence, during the operation of the facility, of any of the events specified...a report shall be made to the licensing agency within the agency's next working day... In addition, a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event.(1) Events reported shall include the following: (E) Any unusual incident...which threatens the physical or emotional health or safety of any client. This requirement was not met as evidence by:
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Licensee to submit updated report to LPA by POC due date.

Licensee shall read regulation 80061 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview, an incident of mice presence in the facility was not reported to licensing per regulatory required time frame. This posed an immediate health and safety risk to residents in care.
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Type A
07/31/2023
Section Cited
CCR80087(g)(1)

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Buidings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Licensee secured dangerous items and chemicals during LPAs visit.

Licensee shall read regulation 80087 and submit a signed declaration of understanding to LPA by POC due date.
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This requirement was not met as evidenced by: Based on observation, Licensee did not ensure laundry detergent, fluid cleaning supplies and a hammer locked in designated storage cabinet. This poses an immediate health and safety risk to residents in care.
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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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/28/2023 04:03 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/28/2023 at 02:56 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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2023
Section Cited
CCR
80064(a)(3)

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80064 Administrator - Qualifications and Duties. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee and staff to complete training on reporting requirements and housekeeping principals. Training to be completed by outside vendor. Training date to be submitted to LPA by POC due date. Proof of completed training to be completed no later than 2 weeks from date of issuance and submitted to LPA upon completion.
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Based on interview and record review, Administrator did not demonstrate compliance with reporting requirements regarding mice presence in facility, nor demonstrate a timely response to incident, which posed an immediate health and safety risk to residents in care.
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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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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