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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002232
Report Date: 08/21/2023
Date Signed: 08/21/2023 03:31:27 PM

Document Has Been Signed on 08/21/2023 03:31 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:DE ORO GUEST HOME #2FACILITY NUMBER:
397002232
ADMINISTRATOR:DORIS B MADRIDFACILITY TYPE:
735
ADDRESS:1648 KNICKERBOCKER COURTTELEPHONE:
(209) 670-4458
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
08/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Doris MadridTIME COMPLETED:
03:45 PM
NARRATIVE
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On 8-21-23 at 1:40pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding an incident which occurred on 7-25-23. LPAs met with Administrator Doris Madrid and explained the purpose of the visit. LPAs also reviewed incident report dated 7-28-23 as well as physician's report and needs and service plan for resident1 (R1). Based on interviews and record reviews, it was determined that on 7-25-23 at approximately 3:40am, facility staff woke up and checked R1's room and discovered R1 to be sleeping. At 5:30am, facility staff woke up to prepare breakfast and checked R1's room. At that time, facility staff discovered R1 was not in R1's room. Facility staff checked the rest of facility and was unable to locate R1. It was further revealed Licensee drove around nearby shopping center and other locations but unable to locate R1. Based on record review and interview, it was additionally revealed that facility's protocol is to call police and file a missing person report if residents do not return by 10pm. A review of R1's physician's report revealed R1 is able to leave facility unassisted, however, record reviews and interview revealed R1 did not sign out resulting in staff unaware of R1's whereabouts, and an absence of supervision of R1. Furthermore, it was revealed that a missing persons report was not made until the night of 7-25-23 at 8:55pm. At this time, based on interview conducted, R1 has not returned to the facility and is currently on the "Con-Rep Program."

Based on today's case management, a citation is issued under Title 22, Division 6. A civil penalty in the amount of $500 is assessed due to the occurrence of absence of supervision. An exit interview was conducted with Doris Madrid and a copy of this report was provided to Doris. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023
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 08/21/2023 03:31 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/21/2023 at 03:08 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: DE ORO GUEST HOME #2
FACILITY NUMBER: 397002232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2023
Section Cited
CCR
80078(a)

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Responsiblity 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 read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will submit a plan outlinining procedures on mainaining awareness of residents whereabouts. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, R1 exited facility at 5:30am on 7-25-23 and did not sign out which resulted in staff unaware of R1's whereabouts and an absence of supervision. This posed an immediate 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: 08/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2023


LIC809 (FAS) - (06/04)
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