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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000569
Report Date: 11/25/2024
Date Signed: 11/25/2024 01:58:16 PM

Document Has Been Signed on 11/25/2024 01:58 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:
11/25/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Kathleen Quiaot, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 11/25/2024, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a Case Management Quarterly Visit. LPA Campbell met with Administrator Kathleen Quiaot and explained the purpose of the visit. All the residents were in Day Program and not present in the facility. The Administrator Quiaot and Caregiver Florencia Yadao were present. Both were finger-print cleared and are associated to the facility.

In regards to the requirement that the licensee will create a plan on how items brought into the facility will be inventoried and stored, LPA Campbell observed that staff have logged when residents have been searched for weapons and sharp objects. However, no procedure was found. LPA Campbell consulted and clarified with the administrator that they will create a Plan of Operation addendum for updating client's IPP in regards to cutting behaviors and email it to LPA Campbell. The administrator stated they had been documenting inventory for R1 because scissors had been found in their bedroom and R1 had used it to cut themselves per the Incident Report submitted on January 04, 2024.

In regards to staff training, LPA Campbell reviewed the last training agenda from the 05/07/2024 Case Management Report that covered Behaviors. When asked to provide documentation of the most recent training, the administrator stated staff had training and Loss and Regulations on 11/22/2024. As verification, the administrator was able to provide an email receipt for the class payment from the vendor and the list of staff taking the training that was provided to the vendor. LPA Campbell requested that the verification be sent to LPA Campbell via email.

In regards to Technical Support Program (TSP) participation, per the Case Management on
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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: 11/25/2024
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08/14/2024, the administrator has been registered for the Technical Support Program but the administrator states, they have not been contacted by TSP. LPA Campbell will verify if the registration request has been received by TSP and inform the administrator when to expect communication from TSP.

In summary, the facility will provide:
  • Plan of Operation Addendum to Prevent Sharp Objects and Weapons from Entering the facility,
  • Topics covered during the training on 11/22, and a Sign In Page for all participants
  • Proof of classes taken on 11/22 (certificate)

All items will be emailed to LPA Campbell by 12/05/2024.

Exit interview. A copy of the report was issued.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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