397001463-9-19-2022-27-AS-RWAE-CJETRE-20220919145726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397001463
Report Date: 09/19/2022
Date Signed: 09/19/2022 02:57:32 PM

Document Has Been Signed on 09/19/2022 02:57 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:	NEW HOPE GUEST HOME		FACILITY NUMBER:	397001463
ADMINISTRATOR:	ROBERT FELIX		FACILITY TYPE:	735
ADDRESS:	526 PALOMA AVENUE		TELEPHONE:	(209) 478-3089
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY: 6		CENSUS: 5	DATE:	09/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Joan Talaroc - Administrator		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Wallace arrived at this facility unannounced to conduct an Required 1 - Year Annual Inspection Visit. LPA met with the administrator and explained the purpose of the visit. LPA Wallace and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed adult residential facility with a current census of 5. There is a hole in ceiling of staff room #2. Facility has a living room/tv room and dining area off the kitchen. There is a locked shed in the backyard not accessible to residents in care. No obstructions to fire exits noted. There are 5 rooms for clients in care. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Water temperature reads 113.2F in the kitchen sink and room temperature reads 73F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were checked 2/7/2022. Facility has an emergency food and water kit. Facility is conducting quarterly fire drills, last one conducted 8/20/2022. LPA observed mitigation plan completed. First aid kit observed to be complete. Emergency Disaster Plan completed on 08/31/2021. LPA reviewed 3 of 5 resident records. LPA reviewed 4 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed current first aid certificates and are current. One deficiency was observed and cited from the California Code of Regulations, Title 22. Exit interview conducted with administrator. A copy of reports and appeal rights given to administrator.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

Document Has Been Signed on 09/19/2022 02:57 PM - It Cannot Be Edited

Created By: Ruth Wallace On 09/19/2022 at 02:52 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: NEW HOPE GUEST HOME	FACILITY NUMBER: 397001463
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2022

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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in staff room #2 has a hole in the ceiling which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit picture of patched hole and painted to LPA Wallace via email by Plan of Correction Date 9/26/2022. ruth.wallace@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Stephen Richardson

LICENSING EVALUATOR NAME:

Ruth Wallace

LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2