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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 10/01/2021
Date Signed: 10/01/2021 04:49:18 PM

Document Has Been Signed on 10/01/2021 04:49 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:MELMAR'S GUEST HOME #3FACILITY NUMBER:
397001192
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:5465 GOVERNOR CIRCLETELEPHONE:
(209) 323-4193
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
10/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Ildefonso LetranTIME COMPLETED:
04:45 PM
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On 10/1/21 at 3:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 8/27/21 involving Resident1 (R1) combativeness with Administrator LPA met with facility manager Illedfonso Letran and explained the purpose of the visit. Administrator Maricor Camero was not present and gave permission by phone for Ildefonso Letran to sign in her absence.

LPA conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. All sharp objects and toxins were secured and inaccessible to clients in care. Room temperature was adequate during today’s visit. There are no obstructions to fire exits inside or outside facility. There was 1 staff on duty during visit. Facility is a level 3 Adult Residential Facility.

LPA reviewed and requested copies of R1's Individualized Program Plan (IPP) and physician’s report. Facility care notes, and incident report dated 8/27/21 were also reviewed. LPA also interviewed facility manager, R2, and R3. R1 was not present in facility as R1 has since moved out after reported incident. Based on interviews and record reviews it was revealed that R1 was addressed by Administrator on 8-27-21 regarding clutter kept in her room and causing a potential fall hazard. According to facility manager who was on duty at the time, R1 became aggressive verbally and physically as a result of being advised to remove clutter, and shoved Administrator causing an injury to Administrator. Facility manager stated police arrived and took R1 to the local crisis center for evaluation; Administrator was admitted to the hospital for evaluation of her injuries. Interview with facility manager and review of care notes revealed that R1 moved out of the facility on 9/3/21 with assistance by regional center and after an assessment by regional center service provider.

Review of R1's IPP reveals resident has a history of verbal and physical aggression including property destruction. Review of R1s physician's report reveals that R1 is able to leave facility unassisted and able to care for all personal needs.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MELMAR'S GUEST HOME #3
FACILITY NUMBER: 397001192
VISIT DATE: 10/01/2021
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Due to unavailability of an individual for an additional interview, additional time is required to complete this case management. Licensee will be notified at a later date for completion and closure of this case management.


Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit.

An exit interview was conducted with Ildefonso Letran and a copy of this report was left with Ildefonso.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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