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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701318
Report Date: 04/02/2025
Date Signed: 04/02/2025 04:07:15 PM

Document Has Been Signed on 04/02/2025 04:07 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:ESTEEMED RESIDENTIAL CARE 2FACILITY NUMBER:
392701318
ADMINISTRATOR/
DIRECTOR:		WALTERS, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:2431 ETCHEVERRY DRIVETELEPHONE:
(925) 219-2787
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 4CENSUS: 5DATE:
04/02/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:21 PM
MET WITH:Christopher WaltersTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 4/2/2025 at 3:21pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to conduct a case management visit. LPA met with Administrator Christopher Walters and explained the purpose of the visit. During an investigation regarding complaint # 27-AS-20250116080733, LPA conducted interviews with three staff members and one resident. LPA also reviewed facility file documentation including staff training records, physician’s report for resident1 (R1), care notes for R1, individual program plan (IPP) for R1, and photographs pertaining to allegation. Based on interviews and record reviews, it was determined that on 1-8-25, R1 engaged in a behavior episode involving self injurious behavior, attempting to hit staff, and property destruction which prompted staff members on duty to perform a manual restraint involving the escorting of R1 to his bed. This manual restraint consisted of staff grabbing upper arms of R1 on both sides. Interviews conducted revealed manual restraint was used due to risk of self injury and injury to staff during this behavior episode. Upon further review of training records, it was determined that staff members who exercised the manual restraint had incomplete training records and invalid certification for use of manual restraints per regulatory requirements. {Cont. on 809C}
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Michael Bilger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ESTEEMED RESIDENTIAL CARE 2
FACILITY NUMBER: 392701318
VISIT DATE: 04/02/2025
NARRATIVE
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Staff1 (S1) completed de-escalation training on 1-2-25 with 4 contact hours; additionally, S1’s training for non-violent intervention consisted of 13.5 hours and expired on 8-16-24. Staff2 (S2) competed course on managing aggressive behaviors with noted date of 2023 and no further training recorded.

As a result of this case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Michael Bilger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2025 04:07 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/02/2025 at 03:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESTEEMED RESIDENTIAL CARE 2
FACILITY NUMBER: 392701318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
85165(b)

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85165(b) Emergency Intervention Staff Training. (b) Staff who use, participate in, approve, or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. This requirement was not met as evidenced by:
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Licensee to ensure completed and certified staff training on emergency interventions for all applicable staff. Proof of completed training to be sent to LPA by POC due date.
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Based on interview and record review, S1 and S2 had missing and insufficient training hours and certification of emergency intervention training. This posed a potential 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Michael Bilger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
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