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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001613
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:11:40 PM

Document Has Been Signed on 10/30/2023 01:11 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:GOLDEN ACRES HOME AND CARE IIFACILITY NUMBER:
397001613
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
735
ADDRESS:2002 E. HARDING WAYTELEPHONE:
(209) 943-5420
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 15CENSUS: 14DATE:
10/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Flordeliza AgtangTIME COMPLETED:
01:20 PM
NARRATIVE
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On 10-30-23 at 10:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding a previous absence without leave (AWOL) incident. LPAs met with lead caregiver Flordeliza Agtang and explained the purpose of the visit. LPA Bilger spoke with Administrator Marivic Teano-Chua by phone and explained the purpose of the visit. LPAs conducted brief interviews with staff1 (S1) and S2. LPAs also reviewed incident report dated 10-12-23 as well as physician's report for resident1 (R1), needs and service plan for R1, and care notes for R1. LPA's conducted a brief facility observation. This observation revealed facility has 8 rooms available for residents and a sign in, sign out sheet is established for resident use. Based on interview and record reviews, it was determined that on 10-11-23, facility staff was conducting rounds at approximately 2:00am and discovered R1 was not in bed or bathroom. Facility staff attempted to locate R1 by searching throughout facility and driving to nearby stores and parks in the area. Facility staff also contacted local law enforcement to file a report, and law enforcement arrived at facility at 2:45am to gather additional details. Licensing department was notified of incident within regulatory time frames.

Upon further record review and interview, it was revealed that on 3-3-23, R1 had a previous attempt to AWOL from facility but was successfully redirected by staff. Additionally, it was revealed that facility did not utilize an internal plan of action to help mitigate potential further occurrences of AWOL for R1 given R1's history of attempting to AWOL. Physician's report states R1 is allowed to leave unassisted, however, R1 did not utilize the sign in and sign out procedure established further resulting in an absence of supervision on 10-11-23. Facility was unaware of R1's whereabout until 10-13-23 when local hospital notified facility staff that R1 was residing in the hospital after being found unresponsive on 10-11-23 at 4:52pm.

As a result of today's case management, citation is issued under Title 22, Division 6 and noted on 809D. A civil penalty in the amount of $500 is issued in addition to the citation due to the occurrence of absence of supervision. An exit interview was conducted with Flordeliza Agtang and a copy of this report was provided to Flordeliza. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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 10/30/2023 01:11 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/30/2023 at 12:16 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: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2023
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 was not met as evidenced by:
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Licensee will submit a plan outlining procedures for ensuring the knowledge of general whereabouts for residents in care. Plan to include but not be limited to: Sign in/Sign out procedures and routine checks on residents in care.
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Based on interview and record review, R1 exited facility with staff unaware of R1's whereabouts between 10-11-23 and 10-13-23 resulting in an absence of supervision. This posed an immediate health and safety risk to resdient 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: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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