397001916-8-30-2022-27-AS-KLES-CHSTJA-20220830144601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397001916
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:46:52 PM

Document Has Been Signed on 08/30/2022 02:46 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	DOUGHERTY'S GUEST HOME		FACILITY NUMBER:	397001916
ADMINISTRATOR:	DOUGHERTY, MIKE		FACILITY TYPE:	735
ADDRESS:	8308 ALEXA COURT		TELEPHONE:	(209) 565-5612
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY: 6		CENSUS: 6	DATE:	08/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Amy Larimer		TIME COMPLETED:	03:15 PM

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Licensing Program Analysts (LPA's) Kesha Lewis and Albert Johnson arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's were met by Staff member and Administrator joined 5 minutes later. LPA'S were screened upon entry for COVID precautions. LPA's explained the purpose of the visit to Administrator. Administrator's Certificate # 6005717735 Expires 12/16/2023

LPA's and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care. LPA's also conducted the infection control domain tool.

Hot water temperature was measured at 90 F degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees Fahrenheit. Advisory given. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

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.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DOUGHERTY'S GUEST HOME	FACILITY NUMBER: 397001916
	VISIT DATE: 08/30/2022

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LPA's observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA's observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.

LPA reviewed two (3) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

LPA Lewis requested updated copies via email to LPA by September 06, of Infection control plan including Monkey pox.

Exit interview held with staff and copies of reports left at conclusion of visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

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