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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701350
Report Date: 12/04/2024
Date Signed: 12/05/2024 09:08:40 AM

Document Has Been Signed on 12/05/2024 09:08 AM - 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:LA HACIENDA CARE MANTECA, LLCFACILITY NUMBER:
392701350
ADMINISTRATOR/
DIRECTOR:		VALLARTA, ANABELEN D.FACILITY TYPE:
740
ADDRESS:597 HACIENDA AVENUETELEPHONE:
(510) 709-7078
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Tomas BelloTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced Plan of Correction visit made out to this facility on 12/04/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Tomas Bello. A brief interview was conducted with the facility staff person at this time. This LPA requested that the facility staff person go ahead and contact the facility Licensee, Lillian Bello Wisco, to inform her that CCL was present at this time.
The facility Licensee, Lillian Bello Wisco, was not present and not able to come to this facility at this time. A facetime call was conducted with the facility Licensee over the phone. A brief interview was conducted with the facility designated Licensee.
Current census was 4 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from prior post licensing visit conducted on 09/30/2024. This visit was to follow up on the Plans of Correction that were due.
The following deficiencies were observed and cited on 09/30/2024:
  • All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350
VISIT DATE: 12/04/2024
NARRATIVE
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  • A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f).

  • The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

It was learned that all of the citations have not been addressed nor brought back into compliance at this time. The plan of corrections have not been completed and submitted into CCL, for review by this LPA, as requested on the LIC 809-D documents dated on 09/30/2024.

All of the above deficiencies will be re-cited and given a new due date for completion, and submission, of the plan of corrections on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/05/2024 09:08 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/04/2024 at 01:24 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: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
CCR
87411(f)

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All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than (6)
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The facility designated Administrator stated that all facility staff providing care and supervision to the residents will be scheduled with their licensed medical professional to undergo and receive clearance for TB. A statement of correction, along with a copy of the cleared TB tests, will be completed and
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months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
Based on a record review, the licensee did not comply with the section cited above in [2] out of [5] facility personnel were not properly cleared for TB which poses an immediate health, safety or personal rights risk to persons in care.
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submitted into CCL by the due date.

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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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/05/2024 09:08 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/04/2024 at 01:25 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: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
CCR
87208(d)

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A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f).
This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above in [1] out
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The facility designated Administrator stated that an updated Plan of Operation will be completed and submitted into CCL addressing the rules and policies in order to accept and retain bedridden residents at any given time. A statement, along with this completed and updated Plan of
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of [3] facility residents were deemed to be bedridden and this facility does not have an updated Plan of Operation to address the rules and policies in order to accept and retain bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.
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Operation, will be completed and submitted into CCL by the due date.
Type A
12/05/2024
Section Cited
HSC1569.618(c)(3)

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The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at
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The facility designated Administrator stated that all facility personnel providing care and supervision to the residents will be scheduled to undergo and complete First Aid training. A statement of correction, along with copies of updated First Aid training certificates/cards, will be completed and submitted into CCL by
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all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Based on a record review, the licensee did not comply with the section cited above in [2] out of [5] facility personnel were missing updated certified First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
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the due date.
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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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