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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701217
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:11:26 PM

Document Has Been Signed on 08/08/2023 04:11 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:
08/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ruby Ana EscoridoTIME COMPLETED:
04:28 PM
NARRATIVE
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On 8-8-23 at 1:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding safeguarding of personal items. LPAs met with Administrator Ruby Ana Escorido and explained the purpose of the visit. LPAs interviewed Staff1 (S1), S2, and resident1 (R1). LPAs also reviewed current Personal and Incidental (P&I) records for R1, admissions agreement for R1, and receipt of item purchase. Based on interview and record review it was determined that facility experienced a presence of mice in the facility which resulted in damage to one of R1's clothing item. It was further determined that clothing item has since been replaced by Licensee on 7-26-23.

Additionally, based on interview, it was revealed that S1 transported R1 to Modesto for R1's personal needs approximately 7-15-23. It was further revealed that R1 paid $30 to S1 for transportation services and owed another $20 per verbal agreement. Based on record review, it was determined that there was no written agreement for said service and admission agreement does not contain a clause indicating additional fees for any type of transportation. As a result, Licensee has agreed to reimburse R1 the money paid thus far to S1.

Based on today's case management visit. Citation is issued under Title 22, Division 6. An exit interview was conducted with Ruby Ana Escorido and a copy of this report was left with Ruby. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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Document Has Been Signed on 08/08/2023 04:11 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/08/2023 at 03:21 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: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
80026(b)

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Safeguards for cash resources, personal property, and valuables of residents. (b) If such a client is accepted for or maintained in care...personal property...shall be safeguarded...This requirement was not met as evidenced by:
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Licensee will submit a plan regarding how resident items will be safeguarded as necessary to prevent damage or loss. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure the safeguarding of R1's personal clothing item during a presence of mice in facility. This posed a potential health, safety, and resident rights risk to residents in care.
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Licensee will read regulation 80026(b) and submit a signed declaration of understanding to LPA by POC due date.

Licensee replaced damaged item on 7-26-23.

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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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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