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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000569
Report Date: 05/13/2024
Date Signed: 07/03/2024 08:31:33 AM

Document Has Been Signed on 07/03/2024 08:31 AM - 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: DATE:
05/13/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:QUIAOT, KATHLEENTIME VISIT/
INSPECTION COMPLETED:
09:53 AM
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A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated non compliance. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPA) Kesha Lewis and Kathryn Thomas, Long term Care Ombudsman and Licensee Kathleen Quiaot. The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action.

Citations for the past 3 years - one (1) A type for fire clearance.

A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee.


On 2-22-24, Licensee was issued a citation under the California Code of Regulations (CCR), Title 22 section87464(f)(1) NEGLECT & LACK OF SUPERVISION and Title 22 section 87405(h)(5) Administrator - Qualifications and Duties due to the licensee not ensuring adequate care and supervision was provided with appropriate regard for the residents' needs which a resident on resident altercation.

Issues discussed related to the above include:



1. A plan ensuring appropriate supervision based on residents’ specific needs per their IPP

2. Ensure completed staff training on the topic of care and supervision, IPP, and reporting requirements

During the meeting on 05/16/2024, the facility agreed to the following:


1. Submission of LIC 500 Personnel Summary for supervisory changes facility to include Administrator presence with no less than 40 hours per week by 5-18-24.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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: WILLOW CARE HOME
FACILITY NUMBER: 397000569
VISIT DATE: 05/13/2024
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Continued from LIC 9111-2...

2. Submission of LIC 500 Personnel Summary for facility to include Administrator presence with no less than 40 hours per week by 5-18-24.

3. Licensee will create a plan on how items brought into the facility will be inventoried and send to the department by 5/24/2024.

4. Licensee will submit the LIC 308 to the department by 5/18/2024.

5. Participation in the Technical Support Program.


Completing the non-compliance conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Codes if such action is deemed necessary by the Regional Manager.

In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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