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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:08:20 AM

Document Has Been Signed on 04/08/2022 11:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 478-4811
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator - Maricor JusonTIME COMPLETED:
11:10 AM
NARRATIVE
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection visit. LPA met with the Administrator Maricor Juson and explained the purpose of the visit. Administrator Certificate expires 3/24/2023.
LPA Wallace inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. Facility is a 2 story home with all client bedrooms upstairs. All clients are ambulatory. There is a dining nook off the kitchen area. There are 4 bedrooms, all shared, and 3 bathrooms. There is 1 bathroom downstairs. There is tool shed in backyard which was unlocked with paint cans and plant food. Can of gals lighter on box in patio area. Licensee locked shed up immediately. LPA also conducted the infection control domain tool. Backyard needs to be mowed. Behind shed old wood needs to be removed, empty buckets, old doors, screens, and debris taken to dump.
The facility submitted a LIC 808 mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID19 room/bathroom if needed. Common touch surfaces are cleaned after each use. -
Water temperature reads 108.2*F in the bathroom and room temperature reads 72*F . LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers expire 7/1/22. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, the following deficiencies were observed during this visit. Exit interview was held with Administrator. A copy of reports and appeal rights left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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Document Has Been Signed on 04/08/2022 11:08 AM - It Cannot Be Edited


Created By: Ruth Wallace On 04/08/2022 at 10:47 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in two paint cans and plant food were in unlocked shed. A can of gas lighter was on backporch which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2022
Plan of Correction
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Licensee immediately put gas lighter and locked all chemicals in the shed while LPA observed. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/08/2022 11:08 AM - It Cannot Be Edited


Created By: Ruth Wallace On 04/08/2022 at 10:47 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the lawn needs mowing for safety of clients walking through backyard. Behind shed debris, old wood, doors, screens, and empy buckets need to be taken to the dump, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee agrees to mow backyard. Remove all debris, old wood, doors, screens, and buckets from behind shed by Plan of Correction date of 4/29/2022. Licensee will submit pictures via email to LPA of yard and removed items from behind shed. ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
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