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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:25:49 PM

Document Has Been Signed on 10/20/2023 01:25 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) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
10/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maricor JunsonTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10-20-23 at 12:45pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding medication procedures. LPA met with Administrator Maricor Junson and explained the purpose of the visit. LPA interviewed Administrator and additional documentation pertaining to complaint #27-AS-20231004110324 including incident report dated 9-24-23, individualized program plan (IPP) for resident1 (R1), and photograph submitted by facility. Based on interview and record reviews it was revealed that various facility staff including Administrator did not appropriately ensure R1 consumed medication as prescribed by R1’s physician. According to interviews, R1 was handed medication by facility staff on multiple occasions and walked away from staff without staff verifying actual consumption by R1. On 9-24-23 upon R1’s move out, Administrator discovered multiple medications inside and out of original packaging stored in R1’s jacket and other sections of R1’s room which were not secured and accessible to R1 and potentially other residents in care. A photograph submitted by facility staff illustrated multiple medications and confirmed by Administrator to belong to R1. Review of R1’s IPP states facility is to ensure R1 takes medication as prescribed.

As a result of this case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Maricor Junson and a copy of this report was left with Maricor. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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 10/20/2023 01:25 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/20/2023 at 12:34 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: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2023
Section Cited
CCR
80075(k)(1)

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Health Related Services. (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Licensee will read regulation 80075 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, facility staff did not appropriately ensure R1 consumed medication as prescribed, resulting in R1 storing multiple medication in pocket of R1’s jacket and other areas of his room and accessible to R1 and potentially other residents. This posed an immediate health and safety risk to residents in care.
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Type A
10/23/2023
Section Cited
CCR80064(a)(2)

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80064(a)(2) Administrator Qualifications and Duties. (a) The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients…This requirement was not met as evidenced by:
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Licensee to read regulation 80064(a)(2) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Administrator did not exercise the knowledge of the required procedure to ensure R1 takes medication as prescribed as stated in R1’s IPP. This posed an immediate health and safety risk to residents in care.
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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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
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