<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701350
Report Date: 12/04/2024
Date Signed: 12/05/2024 09:09:07 AM

Document Has Been Signed on 12/05/2024 09:09 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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Tomas BelloTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Unannounced Case Management - Deficiencies 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.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

A civil penalty in the amount of $500 was issued during today's case management visit on the following LIC 421IM (7/17).

Appeal Rights were printed and a copy was given to the facility staff person Tomas Bello at this time.

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
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 2
Document Has Been Signed on 12/05/2024 09:09 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/04/2024 at 01:47 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)

1
2
3
4
5
6
7
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
1
2
3
4
5
6
7
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
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14
Operation, will be completed and submitted into CCL by the due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 2 of 2