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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002666
Report Date: 09/10/2021
Date Signed: 09/10/2021 05:34:38 PM

Document Has Been Signed on 09/10/2021 05:34 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:GOVERNOR CIRCLE CARE HOMEFACILITY NUMBER:
397002666
ADMINISTRATOR:LAGUA, MARCELINAFACILITY TYPE:
735
ADDRESS:5435 GOVERNOR CIRCLETELEPHONE:
(209) 954-0327
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Eddie Nieves, Lead CaregiverTIME COMPLETED:
05:35 PM
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On 9-10-21 at 3:28pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the lead caregiver Eddie Nieves and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed adult residential facility with a current census of 5. Facility has 4 bedrooms for clients in care. There is a separate living and TV room. A dining area is off of the kitchen. An emergency exit as designated on the facility sketch was inoperable during today's visit due to a broken lock obstructing it from opening. 30-day supply of PPE observed in facility. All toxins and sharp objects are not accessible to clients in care. LPA also conducted the infection control domain tool.
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. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
Water temperature reads 114.2*F in the bathroom and room temperature reads 77*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 11/3/2020 . Facility has an emergency food and water kit.
Per California Code of Regulations, Title 22, Division 6, deficiencies were observed during this visit as noted on LIC 9099D. An immediate civil penalty of $500 is assessed in addition to the citation issued. Exit interview was held and a report along with appeal rights was given to Lead Caregiver Eddie Nieves
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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 09/10/2021 05:34 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/10/2021 at 04:57 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: GOVERNOR CIRCLE CARE HOME
FACILITY NUMBER: 397002666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Emergency exit in the garage was obstructed by a broken lock which disallowed passage to the outside, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 09/11/2021
Plan of Correction
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Licensee will repair door and lock to operable condition allowing passage to the outside. Licensee to submit detailed photo proof of repair to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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