392790075-4-13-2026-27-AS-NWPN-DT4QQT-20260413122253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 04/13/2026
Date Signed: 04/13/2026 12:23:31 PM

Document Has Been Signed on 04/13/2026 12:23 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:	HAYNES BOARD AND CARE		FACILITY NUMBER:	392790075
ADMINISTRATOR/ DIRECTOR:	PARKER, CHERYL		FACILITY TYPE:	735
ADDRESS:	17201 N. TULLY ROAD		TELEPHONE:	(209) 727-5834
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY: 30		CENSUS:	DATE:	04/13/2026
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Sandra, Cheryl, Melissa		TIME VISIT/ INSPECTION COMPLETED:	11:27 AM

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	Today, 4/13/26 at 11am, an informal meeting was held regarding a recent complaint at Haynes Board and Care. In attendance was Licensing Program Analysts, Noel Wolf Petersen and Kesha Lewis, Licensing Program Manager Liza King, Facility Representatives Administrator Melissa Girardot, Licensee Sandra Haynes, Anna Sims Quality Control at VMRC, and former administrator/current Licensee Cheryl Parker, and Ombudsman Katina Richardson. After introductions, the meeting begins: The meeting is called regarding the facilities first substantiated complaint in six years of operation. a member of the staff and administrator of record at the time of the incident was found by the LPA Noel Wolf Petersen to be substantially likely to have participated in undignified interactions with a resident, for example a staff calling a resident a bitch. In interviews of staff and residents, multiple statements characterized the member of staff as mean, rude, or overly forceful in tone, corroborating the claim. The department is shocked with the record of the facility being exemplary, and is seeking a robust amount of training to avoid any possible future situation of this kind. The licensee provided comment about the complaint/LPA: the length of time turning around from the start of the complaint to this meeting was very long, just about 6 months. We will be looking forward and doing our best. Both sentiments are shared around the group. In addition, Licensee provided comment about changes made since the complaint: Continued on c page:

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026

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: HAYNES BOARD AND CARE	FACILITY NUMBER: 392790075
	VISIT DATE: 04/13/2026

NARRATIVE

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Administrator paper work was submitted, designating new administrator Melissa Girardot
New trainings for all staff regarding client rights, respect and dignity, and grievance procedure (this new training took a few couple meetings for all the staff to be trained)
resident council meetings are taking place
new internal grievance policy

The Licensee provided comment that there is participation with the new grievance policy from residents involved with the complaint and they reported feeling empowered.

The department asked for communication specific training, and Sims provided details about HCBS funded training, that every month that vmrc is providing on Person Centeredness type topics. The Department is asking for attendance of Cheryl Parkers in 3 trainings in 3 months for Personal Rights/Communication type topics, and then once an quarter for the rest of the year(until 4/2027). Submit signed training rosters and topics to LPA Kesha Lewis quarterly(june 2026, september 2026, december 2026, march 2027).

At the conclusion of the meeting, the Licensee was advised of measures taken to ensure increased compliance:

The facility will have Quarterly visits from the department until 4/2027, to be extended or ended at a future date, focusing on:
a review of the personal rights/communication training
a review of the resident council meeting minutes, any actions taken by the facility
a review of the new internal grievance procedures, any actions taken by the facility

The meeting was concluded at 11:27am, a copy of the report was read and provided to the administrator. A copy of the report was requested by the department to be sent back with a signature from the LPA. exit interview.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026

LIC809 (FAS) - (06/04)

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