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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000569
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:11:59 PM

Document Has Been Signed on 05/03/2024 12:11 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:WILLOW CARE HOMEFACILITY NUMBER:
397000569
ADMINISTRATOR/
DIRECTOR:		QUIAOT, KATHLEENFACILITY TYPE:
735
ADDRESS:1633 WILLOW PARK WAYTELEPHONE:
(209) 462-2923
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 3DATE:
05/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:QUIAOT, KATHLEENTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit regarding an incident that occurred on 02/23/2024. LPA was greeted by staff and licensee joined about 20 minutes later LPA explained the reason for the visit.

The department investigated this incident and it was determined to be substantiated. The Department conducted interviews with three staff members and residents. Admin, S1, S2 and collaborating agency representatives(See confidential name list LIC-811 dated 5/03/2024) all provided statements to the department that confirm that R2 had a history of bringing potentially dangerous objects into the facility upon returning from community outings. Based on records reviewed the facility failed to create a plan to prevent R2 from bringing items into the facility that could be dangerous. R1 was stuck with a crowbar by R2. S1, S2, R1, R2 and the Administrator confirm that the incident occurred.


During the investigation, it was found that there were other incidents were R2 had brought items into the facility and staff would not check R2'S room and bags to see if there were any items that could cause harm even though a plane was to have been put in place for this, also the facility failed to report incidents with R2.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. A civil Failure to correct the deficiencies may also result in civil penalties.

Exit interview and copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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Document Has Been Signed on 05/03/2024 12:11 PM - It Cannot Be Edited


Created By: Kesha Lewis On 05/03/2024 at 10:48 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WILLOW CARE HOME
FACILITY NUMBER: 397000569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2024
Section Cited
CCR
80064(a)(2)

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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, including ability to communicate with such clients.
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The Licensee will send an attestation by email to Kesha.Lewis@dss.ca.gov by 5/06/24 that all current resident files will be reviewed and updated for compliance.
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 Based on records reviewed the facility failed to create a plan to prevent R2 from bringing items into the facility that could be dangerous. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type B
05/17/2024
Section Cited
CCR80061(a)(b)

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0061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Licensee agrees to ensure and either conduct training for facility staff or enrolled facility staff to take continued training coursed per title 22 regulation. Licensee will email LPA the completed training documents which include topic of trainings conducted, materials/topic that staff was trained on and sign in sheet of staff that attended the training. By COB 5/17/24.
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Based on observation, the licensee did not comply with the section cited above.

This poses a potential risk to the health, safety and personal rights of 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:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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