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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000457
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:21:36 PM

Document Has Been Signed on 01/24/2024 04:21 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:JAVIER'S GUEST HOMEFACILITY NUMBER:
397000457
ADMINISTRATOR:ESTHER JAVIERFACILITY TYPE:
735
ADDRESS:8127 BURGUNDY DRIVETELEPHONE:
(209) 475-1299
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Shalimar GouldingTIME COMPLETED:
04:30 PM
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On 1-24-24 at 1:48pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Shalimar Goulding and explained the purpose of the visit.

LPA 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 of the facility to ensure compliance with Title 22 regulations. Facility is an adult residential facility with a current census of 5. Facility has 3 bedrooms and 2 bathrooms for resident use. Two additional bedrooms are in use by staff. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 5 ambulatory residents, 0 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved infection control plan in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 69*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 extinguisher was checked 6-23-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 resident files and 2 staffing files were reviewed for regulatory compliance. All files contained required contents. All staff noted on LIC 500 contained criminal background clearances. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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: JAVIER'S GUEST HOME
FACILITY NUMBER: 397000457
VISIT DATE: 01/24/2024
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LPA completed 2 attempted resident interviews and 1 staff interviews. Resident files were reviewed for regulatory compliance. It was further discovered during resident file review that 3 of 5 residents are now over the age of 60. Facility does not contain any bodies of water. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts monthly fire drills. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. Exit interview was held and a report was given to Administrator Shalimar Goulding. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2024 04:21 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/24/2024 at 03:21 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JAVIER'S GUEST HOME

FACILITY NUMBER: 397000457

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and retention limitations. (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients...the licensee must request an exception in order to accept or retain the individual.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in that 3 of 5 clients are age 60 or older, and licensee has not submitted an exception request to licensing department. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee will send a request into licensing asking for an exception to retain 50% or more of residents over the age of 60. Request to be sent to LPA by POC due date
Licensee will read regulation 85068.4 and submit a signed declaration of understanding to LPA by POC due date.
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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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