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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:41:52 PM

Document Has Been Signed on 07/21/2022 03:41 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) 475-8161
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Ildefonso LetranTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7-21-22 at 2:50pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to conduct a case management visit regarding an incident reported to licensing department on 6-17-22. LPAs met with assistant administrator Ildefonso Letran and explained the purpose of the visit. Ildefonso notified Administrator Maricor Camero to make aware of LPAs visit. LPAs reviewed incident report for resident1 (R1) dated 6-17-22 with assistant administrator as well as an “addendum” to the incident report dated 6-18-22 and received by licensing department 6-20-22. Additionally, LPAs reviewed Physician’s Report for R1. LPAs also interviewed assistant administrator. The addendum reviewed also included a 30-day notice of eviction to R1 due to multiple elopement attempts and other behaviors with intended move out date of 7-18-22.

Upon review of 30-day notice, it was determined that notice met regulatory requirements and sent to R1s responsible party on 6-18-22, along with a copy sent to licensing department on 6-20-22. R1 currently continues to reside in facility at this time. LPAs verified through email and fax communication between assistant administrator and R1’s service coordinator that service coordinator was sent the 30-day notice on 6-18-22 and acknowledged.

Incident report dated 6-17-22 stated R1 exited facility on 6-16-22 at approximately 9:20am. LPAs interviewed assistant administrator and reviewed sign in and sign out sheet which indicated R1 did not sign out. LPAs also reviewed Physician’s report for R1 which indicates R1 is able to leave facility unassisted. The incident report reviewed stated “Staff…followed him along the street but couldn’t see him anymore.” Incident report also stated “Two staff were also looking for him but unsuccessful to find him.” Based on record review and interview, it was determined staff was unaware of R1s whereabouts. The addendum to incident report dated 6-18-22 states R1 “was found on the street by Police on June 18, 2022 and was dropped off at Melmar’s Home at about 8:00pm.”

{Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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: 07/21/2022
NARRATIVE
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Addendum to incident report received by licensing department on 6-20-22 stated R1 “walked away from home multiple times and just able to return home when found by staff on the street – May 1, 2022, May 24, 2022, June 8, 2022, after midnight, and June 9, 2022.” Addendum also states R1 fell on the street multiple times while eloping or attempting to elope, in addition to disruptive behavior within facility. Based on record review and interview, it was determined that an incident report was not received by licensing department reflecting the dates noted above and disruptive behavior.

As a result of today’s visit, citations are issued under Title 22, Division 6. An exit interview was conducted with Ildefonso Letran and a copy of this report was left with Ildefonso. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2022 03:41 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/21/2022 at 02:48 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: MELMAR'S GUEST HOME #3
FACILITY NUMBER: 397001192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure staff is aware of clients’ whereabouts at all times. Plan to be submitted to LPA by POC due date.

Licensee will read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews and record reviews, R1 eloped from facility on 6-16-22 at approximately 9:20am and facility staff was unaware of R1's whereabouts until approximately 8:00pm on 6-18-22. This poses an immediate health and safety risk to residents in care.
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Licensee will conduct staff training on elopement procedures and submit proof of completed training to LPA by POC due date.
Type B
08/01/2022
Section Cited
CCR80061(b)(1)(E)

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Reporting Requirements.(b) Upon the occurrence…of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day...In addition, a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Licensee will read regulation 80061 and submit a signed declaration of understanding to LPA by POC due date.

Licensee will ensure completed staff training on regulation 80061 and submit proof completed training to LPA by POC due date
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This requirement is not met as evidenced by: Based on interview and record review, R1 had multiple episodes of elopement attempts between 5/1/22 and 6/9/22 as well as disruptive behavior towards other clients which was not reported to licensing department. This poses a potential health, safety, and resident rights risk to clients in care.
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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: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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