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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701278
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:58:11 PM


Document Has Been Signed on 09/19/2023 12:58 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:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
392701278
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE RDTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 11DATE:
09/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cecelia NunezTIME COMPLETED:
11:45 AM
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On 9/19/23 at approximately 11:30am Licensing Program Analyst (LPA) Jennifer Fain arrived unannounced for a case management into the above allegations. LPA met with Cecelia Nunez and explained the reason for the visit.

Residents were in their rooms or watching TV in the common area. Staff was preparing beef stew and baked potatoes for lunch.

LPA spoke with Staff 1 (S1) about the altercation on 9/17/23. S1 did not witness incident. S1 reported that on 9/19/23 R1 was at the doctor, an appointment that was requested by S1, and was referred to Mental/ Behavioral Health. Mental/ Behavioral Health declined to accept R1 without an evaluation. R1 was sent to the ED for evaluation. After some time had passed, R1 became agitated and left the building. S1 and R1 returned home.

LPA met with Resident 1 (R1) to ask about the incident on the weekend of 9/17/23. R1 does not recall the incident but had several concerns. R1 stated that over the counter supplements had been taken away from her and were given to her at meal times by staff. Per 602 R1 may manage her own prescriptions and PRN medications. R1 stated she would like help getting her dentures replaced. Staff 1 stated she will set up a dental appointment.

R1 agreed she would like a Mental Health appointment at a specific time, she does not wish to wait in the ED. S1 stated she will call the Primary Care Physician and try to get the referral and evaluation completed so R1 will not have to wait in the ED.

An exit interview was conducted with Cecelia Nunez, a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 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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