397000250-12-21-2023-27-AS-MBIR-CYQVEF-20231221152215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:23:19 PM

Document Has Been Signed on 12/21/2023 03:23 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:	MELMAR'S GUEST HOME #2		FACILITY NUMBER:	397000250
ADMINISTRATOR:	CAMERO, MARICOR		FACILITY TYPE:	735
ADDRESS:	6801 MONTAUBAN AVENUE		TELEPHONE:	(209) 683-6876
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY: 6		CENSUS: 4	DATE:	12/21/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maricor Junson		TIME COMPLETED:	02:05 PM

NARRATIVE

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On 12-21-23 at 1:00pm, Regional Office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, LPM Lisa Rios, Licensing Program Analyst (LPA) Michael Bilger, Licensee Maricor Junson, staff1 (S1), and S2, and regional center representative Rukaiyah Jones. Topics in this meeting included the following: (1) Care and Supervision, (2) Personal Rights: Safe and Healthful accommodations, (3) Health Related Services including but limited to: Medication procedures and documentation, (6) Plan of Operation updates, (7) Fire clearance issues, and (8) Administrator Qualifications.

LPA Bilger and LPM King discussed with Licensee the following citations and the associated plans of correction going forward. Please note some citations may be under appeal at this time.

10-20-23: 80075(b) Health Related Services. Licensee did not ensure resident took medication as prescribed.

10-20-23: 80075(k)(1) Health Related Services. Licensee did not ensure resident consumed medication as prescribed resulting in resident storing multiple medications in the jacket pocket and areas of resident’s room.

10-20-23: 80064(a)(2). Administrator Qualifications. Administrator did not exercise the proper procedures for ensuring resident takes prescribed medication.

11-21-23: 80075(b) Health Related Services. Licensee did not ensure resident received a medication as prescribed as indicated on the medication log sheets (civil penalty issued)

11-21-23: 80072(a)(2) Personal Rights. Staff member drove residents in the facility’s vehicle without a license to drive. (Civil penalty issued)

{Cont. on 809C}.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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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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: MELMAR'S GUEST HOME #2	FACILITY NUMBER: 397000250
	VISIT DATE: 12/21/2023

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12-20-23: 80020(a) Fire Clearance. Licensee did not initiate an updated fire clearance procedure after converting the garage and designated recreation room to a staff members living quarters. (Civil penalty issued). The licensee will submit an updated LIC 200 and an updated facility sketch to LPA by 12-22-23 to reflect changes including 2 designated staff living quarters.

12-20-23: 80078(a) Responsibility for Providing Care and Supervision. Resident was on the licensed property without staff presence and supervision. Licensee will now ensure all staff will have a valid driver’s license to operate a vehicle for client transportation.

12-20-23: 80022(j) Plan of Operation. Licensee did not update plan of operation to reflect a previously designated recreation room now converted to a staff member’s room, and no longer available to clients.

12-20-23: 80064(a)(3) Administrator Qualifications. Licensee did not exercise knowledge of regulations requiring licensee to update plan of operation and initiate an updated fire clearance.

LPA, LPM and Regional center representative discussed with Licensee the importance for Licensee to maintain adequate supervision for all clients in care, and a plan to ensure a staff is always present to ensure supervision. Additionally, Licensee was made aware of the importance of documenting medication given to clients as clients receive and consume medication to mitigate further medication errors. Licensee stated she has been contracting with an outside consulting company for additional assistance and training of staff. Recent training has been completed for 4 staff members. Licensee stated medication log sheets will now be next to staff as staff assist clients with medication and document as medication is given. Licensee will develop a consistent audit check to ensure medications have been given and documented.

LPA, LPM, and regional center representative discussed with Licensee to procedures for securing an updated fire clearance and what constitutes an updated fire clearance going forward.

The department is requesting the following to be submitted by the Licensee:

1. Updated LIC 500 to reflect Administrator’s hours on duty and all other staff schedule and hours by 12-22-23.

2. Updated LIC 308 to reflect any designated substitute of Administrator by 12-22-23

{Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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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: MELMAR'S GUEST HOME #2	FACILITY NUMBER: 397000250
	VISIT DATE: 12/21/2023

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3. Updated plan of medication procedures to ensure how residents will receive medication as prescribed and documented accordingly by 12-26-23

4. Staffing schedule for the next 6 weeks reflecting staff on duty including days and number of hours worked by 12-22-23

5. Licensee and staff to ensure on-going medication and personal rights training every 6 months and maintain proof of completion for Departmental review.

The department is requiring Administrator be on duty at facility for no less than 40 hours per week. Department shall conduct quarterly visits to ensure compliance with above and all other Title 22 requirements. Quarterly visits shall consist of, but not be limited to: (1) Review of client and staffing files, (2) Review of medication administration records and procedures, (3) Staffing schedules, (4) Physical plant inspections, and (5) On-going staff training records. LPM and LPAs notified Administrator that future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and a non-compliance conference to discuss further potential administrative action. A referral for Technical Support Program (TSP) will be made to assist Licensee with on-going compliance.

An exit interview was conducted with Maricor Junson and a copy of the report was emailed to Maricor with a request for return with signature

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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