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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:48:28 PM

Document Has Been Signed on 02/23/2023 03:48 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
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) 298-0652
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Maricor JusonTIME COMPLETED:
04:00 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
On 2-23-23 at 2:35pm, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding an incident which occurred on 12-12-22. LPA met with Administrator Maricor Juson and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report dated 12-12-22. Based on interview and record review, it was determined that on 12-12-22, staff1 (S1) had in his possession a personal vitamin pill with intention to dispense to himself. Based on interview, S1 placed his vitamin pill on a med log book and got up from his desk to tend to another resident. When S1 returned his vitamin pill could not be found. Vitamin pill was later found inside the medication log book by Administrator and disposed of in the trash can. Trash was then disposed of outside same day based on interview.

As a result of today's case management, citation is issued under Title 22, Division 6. An exit interview was conducted with Maricor Juson and a copy of this report was provided to Maricor. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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 02/23/2023 03:48 PM - It Cannot Be Edited


Created By: Michael Bilger On 02/23/2023 at 02:52 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
, 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: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited
CCR
80072(a)(2)

1
2
3
4
5
6
7
Personal Rights. (a)...each client shall have personal rights which include...the following: (2) To be accorded safe, healthful and comfortable accommodations....This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will read regulation 80072(a)(2) and submit a signed declaration of understanding to LPA by POC due date.

8
9
10
11
12
13
14
Based on interview and record review, licensee did not ensure a safe, healthful accommodation for residents in care in that S1's personal vitamin pill was lost, found, and disposed of in facility trash can. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee will submit a plan for safety protocols for residents in care to include staff members personal items stored in facility. Proof of training to be submitted to LPA by POC 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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2