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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000618
Report Date: 04/27/2022
Date Signed: 04/27/2022 05:03:31 PM

Document Has Been Signed on 04/27/2022 05:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SOLIDUM CARE HOME #8FACILITY NUMBER:
397000618
ADMINISTRATOR:NORMA SOLIDUMFACILITY TYPE:
735
ADDRESS:217 BERNICE AVENUETELEPHONE:
(209) 477-2413
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Wally CabutajeTIME COMPLETED:
05:06 PM
NARRATIVE
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On 4/27/22 at 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the Caregiver Wally Cabutaje and explained the purpose of the visit. Administrator Lynn Caoli made aware of LPAs visit and purpose. Administrator arrived at 4:13pm

LPA Bilger 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 backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 4. There are 8 bedrooms, 3 bathrooms. 2 bedrooms are for staff use. There is a formal living room, dining room and seperate office off the entry way. LPA also conducted the infection control domain tool.
The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA reviewed 8 staff charts. 6/8 staff charts have expired first aid/CPR certification. 8/8 staff have criminal record clearance. Administrator certificate current and expires 12/4/22. All staff COVID-19 vaccinations current.

Water temperature reads 115.2*F in the bathroom and room temperature reads 70*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed uncovered food items and flying insects in lower left area of kitchen upon opening food storage. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4/22/22. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and citations were issued under Title 22 Exit interview was held with Lynn Caoli and a report was given to Lynn
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/27/2022 05:03 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/27/2022 at 04:08 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOLIDUM CARE HOME #8
FACILITY NUMBER: 397000618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above: LPA observed flying inspects in food storage area in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee will read regulation 80087(a)(1) and submit a signed declaration of understanding licensee to send declaration to LPA by POC due date.
Licensee removed items from food storage area during LPAs visit.
Licensee will contract with pest control to eliminate and control insects. Licensee to submit proof of pest control agreement to LPA by POC due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above: 6 of 8 staffing files contained expired first/CPR certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee to submit proof of scheduled first aid/CPR training for staff members to LPA by POC due date.
Licensee to submit proof of completed training to LPA by 5/4/22.
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: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/27/2022 05:03 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/27/2022 at 04:25 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOLIDUM CARE HOME #8
FACILITY NUMBER: 397000618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above: LPA observed uncovered food items in kitchen food storage area exposed and not discarded accordingly, resulting in attraction of flying insects, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee will read regulation 80076(a)(18) and submit a signed declaration of understanding to LPA by POC due date
Licensee removed uncovered food items from storage area during LPAs visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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