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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002232
Report Date: 10/07/2022
Date Signed: 10/07/2022 11:53:47 AM

Document Has Been Signed on 10/07/2022 11:53 AM - 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:DE ORO GUEST HOME #2FACILITY NUMBER:
397002232
ADMINISTRATOR:DORIS B MADRIDFACILITY TYPE:
735
ADDRESS:1648 KNICKERBOCKER COURTTELEPHONE:
(209) 478-0788
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: DATE:
10/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Nellen Van De PolTIME COMPLETED:
12:05 PM
NARRATIVE
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On 10-7-22 at 9:48am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to an incident report dated 9-18-22. LPA met with Administrator Nellen Van De Pol and explained the purpose of the visit. LPA reviewed incident report with Administrator and interviewed Administrator. LPA also conducted a health and safety check of home. Incident report states resident1 (R1) signed out of facility log book on 9-15-22 at 5:35am and checked self into hospital. Incident report states R1 has had multiple episodes of checking self into hospital. Incident report further stated Administrator will issue a 30-day notice to R1. It was determined based on interview and record review that a copy of Eviction notice was received by licensing department within 5 days of issuance to R1. LPA observed a fax confirmation of notice sent on 9-19-22 to licensing department and R1s responsible person. Additionally, LPA reviewed updated needs and service plan reflecting R1's behavior.

During health and safety check, LPA observed excessive amounts of flies throughout facility including kitchen, common area, and resident bedrooms. Additionally, LPA observed sliding screen for sliding door in resident2 (R2) room to be malfunctioning and containing spider webs and excessive dirt.. Facility temperature was 76*F. No obstructions to fire exits observed today. There are a total of 6 residents currently residing in facility; one staff member and Administrator were on duty during LPA's visit. LPA observed adequate food supply available for residents in care.

Based on today's visit, citations are issued under Title 22, Division 6. An exit interview was conducted with Nellen Van De Pol and a copy of this report was left with Nellen. Appeal rights explained and to be emailed.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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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Document Has Been Signed on 10/07/2022 11:53 AM - It Cannot Be Edited


Created By: Michael Bilger On 10/07/2022 at 11:24 AM
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: DE ORO GUEST HOME #2
FACILITY NUMBER: 397002232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2022
Section Cited
CCR
80088(b)

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Furniture, Fixtures, Equipment, and Supplies. (b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
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Licensee will repair or replace sliding screen in R2's room and submit photo proof of repair or replacement to LPA by POC due date. LPA may conduct POC visit prior to citation clearance.
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Based on LPA observation, window sliding screen for sliding door in R2's room is partially off, not functioning properly, and contains spider webs and excessive dirt. This poses a potential health and safety risk to residents in care.
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Type B
10/17/2022
Section Cited
CCR80087(a)(1)

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Buidling 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.(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
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Licensee will read regulation 80087(a)(1) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will submit an action plan to LPA describing how facility will maintain sanitation and eliminate flies within facility. Plan to be submitted by POC due date.
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Based on LPA observation, facility contained excessive amounts of flies throughout including kitchen, common areas, and resident room locations. This poses a potential health and safety risk to residents 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: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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