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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002232
Report Date: 01/17/2025
Date Signed: 01/17/2025 01:10:53 PM

Document Has Been Signed on 01/17/2025 01:10 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DE ORO GUEST HOME #2FACILITY NUMBER:
397002232
ADMINISTRATOR/
DIRECTOR:		DORIS B MADRIDFACILITY TYPE:
735
ADDRESS:1648 KNICKERBOCKER COURTTELEPHONE:
(209) 670-4458
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Nellen Van De PolTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 1/17/25 at 12:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding a previously reported absence without leave (AWOL). LPA met with Licensee Nellen Van De Pol and explained the purpose of the visit. LPA conducted brief interview with Licensee and reviewed incident report dated 11/28/2024 as well as physician's report for R1. . Based on interview and record review it was determined that on 11/22/2024, resident1 (R1) exited facility at approximately between 4:00pm and 4:30pm. Facility staff were alerted of R1's absence after attempting to notify R1 of dinner. Facility staff searched perimeter of facility and contacted local hospitals to determine whereabouts.

It was further determined that R1 did not sign out resulting in staff unaware of R1's whereabouts and resulting in an absence of supervision. Interview and record review revealed R1 walked into local crisis center at approximately 7:00pm 11/22/2024 and excessively wet due to rain. Additionally, it was noted through record review and interview that R1 has a history of exiting facility without signing out and has a history of suicidal ideations, resulting in Licensee determining a need for "one on one care and supervision" as stated in incident report reviewed.

Incident was reported to Licensing department and local law enforcement within regulatory time frames. R1's physician's report states R1 is able to leave facility unassisted.

As a result of today's case management, citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision resulting from this AWOL. An exit interview was conducted with Licensee and a copy of this report was provided. LIC 811 and appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 01/17/2025 01:10 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/17/2025 at 12:34 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DE ORO GUEST HOME #2
FACILITY NUMBER: 397002232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2025
Section Cited
CCR
80078(a)

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80078 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 develop and submit a plan ensuring accountability of residents' general whereabouts. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, R1 exited facility and staff was unaware of R1's whereabouts, resulting in an absence of supervision. This posed an immediate health and safety risk to resident 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: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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