Community Care Licensing

Document Has Been Signed on 12/22/2024 09:10 AM - It Cannot Be Edited

FACILITY NAME:	UCP OF SAN JOAQUIN.CALAVERAS AND AMADOR		FACILITY NUMBER:	397001415
ADMINISTRATOR/ DIRECTOR:	TONISHA MIXON		FACILITY TYPE:	775
ADDRESS:	7616 PACIFIC AVENUE #A6		TELEPHONE:	(209) 956-0290
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY: 87		CENSUS: 34	DATE:	12/20/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Jane Johnson		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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LPA Johnson arrived unannounced to conduct a plan of correction and case management visit. LPA met with Jane Johnson Monge and explained the purpose of the visit. The following deficiencies, initially cited during a visit on 5/21/2024 and 6/03/2024 have been cleared. Section Cited: 82065.2(a)(1) Date Due: 05/21/2024 Plan of Correction: 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. Corrections: Cleared By Visit Clearance Date: 12/20/2024 Section Cited: 80020 Date Due: 05/21/2024 Plan of Correction: The licensee will conduct a drill by POC date and will continue to stay compliant with drills every six months or more often. Corrections: Cleared By Visit Clearance Date: 12/20/2024 Section Cited: 82092.2(a) Date Due: 06/03/2024 Plan of Correction: 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. Corrections: Cleared By Visit Clearance Date: 12/20/2024

SUPERVISORS NAME: Lisa Rios LICENSING EVALUATOR NAME: Albert Johnson LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024