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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001415
Report Date: 05/20/2024
Date Signed: 05/22/2024 04:01:15 PM

Document Has Been Signed on 05/22/2024 04:01 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:UCP OF SAN JOAQUIN.CALAVERAS AND AMADORFACILITY NUMBER:
397001415
ADMINISTRATOR/
DIRECTOR:		TONISHA MIXONFACILITY TYPE:
775
ADDRESS:7616 PACIFIC AVENUE #A6TELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 87CENSUS: 39DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Hayliey LozaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 5/20/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with H. Loza and explained the purpose of the visit. When LPA arrived the facility had 36 clients and 9 staff. 2 Staff arrived to work this morning not feeling well and were tested for COVID. Both staff tested positive and were sent home.The staffing ratio was out of compliance with the regional center requirements for a 510 Adult Development Center.

LPA inspected the physical plant including but not limited to the kitchen, activity rooms, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 119.5 degrees Fahrenheit in Consumer bathroom sink, which is within the required range of 105 to 120 degrees. Fire/disaster drill was conducted on 9/23/2023.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 consumer/resident and 6 staff files, including criminal record clearances. LPA observed carbon monoxide detectors in the facility. Residents file review observed 3 of 5 restricted health care plan were out of date.

Per the Title 22, Division 6 of California Code of Regulations. Deficiencies were observed during today's inspection.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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Document Has Been Signed on 05/22/2024 04:01 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/20/2024 at 12:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: UCP OF SAN JOAQUIN.CALAVERAS AND AMADOR
FACILITY NUMBER: 397001415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82065.2(a)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interviews and records review the licensee did not comply with the ratio requirements and the section cited above in 5 of 20 days for May of 2024 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Licensee will develop and submit staffing plan to reflect no less than 1:3 staffing ratio. Plan to be submitted to LPA by POC due date.
Type A
Section Cited
CCR
8200


This requirement is not met as evidenced by:
Deficient Practice Statement
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82023 (d)(1)(2)
Based on records reviewed the licensee did not comply with the section cited above. the last drill was conducted on 9/23/2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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The licensee will conduct a drill by POC date and will continue to stay compliant with drills every six months or more often.
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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 04:01 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/20/2024 at 12:51 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: UCP OF SAN JOAQUIN.CALAVERAS AND AMADOR
FACILITY NUMBER: 397001415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82092.2(a)


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 in 3 out of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Licensee/Administrator shall submit an updated health care plan for all residents with a restricted health condition. This shall be done by POC date 6/03/2024.
Section Cited
Deficient Practice Statement
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3
4
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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
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