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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 08/02/2024
Date Signed: 08/02/2024 01:27:21 PM

Document Has Been Signed on 08/02/2024 01:27 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:MELMAR'S GUEST HOME #3FACILITY NUMBER:
397001192
ADMINISTRATOR/
DIRECTOR:		CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:5465 GOVERNOR CIRCLETELEPHONE:
(209) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Ildefonso LetranTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 8/2/2024 at 11:30am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the assistant administrator/Licensee Ildefonso Letran and explained the purpose of the visit. Administrator Maricor Junson was made aware of LPAs visit and purpose.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. LPA observed side gates requiring repair for purposes of swinging freely upon opening. The facility consists of 4 total bedrooms of which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 76 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured between 105 and 120 degrees Fahrenheit. The fire extinguisher was last inspected on 3/13/2024 and all smoke alarms and carbon monoxide alarms were tested successfully. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Facility has an emergency food supply. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible residents in care. Medications were observed to contain required physician's orders. First aid kit was observed to have adequate supplies and accessible to staff. LPA conducted interviews with two staff and one client in care.

All staff noted on LIC 500 contained criminal background clearances.

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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: MELMAR'S GUEST HOME #3
FACILITY NUMBER: 397001192
VISIT DATE: 08/02/2024
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Facility’s surety bond is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. Exit interview was held and a report was given to the assistant administrator Ildefonso Letran. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2024 01:27 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/02/2024 at 12:55 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MELMAR'S GUEST HOME #3
FACILITY NUMBER: 397001192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure side gates on the right and left sides of facility opened and close adequately, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee shall repair or replace side gates to operating standards which includes opening and closing adequately and ability to self latch upon closing. Licensee to provide photo and video proof to LPA by POC due date. LPA may conduct POC visit prior to clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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