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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002666
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:20:17 PM

Document Has Been Signed on 01/11/2024 04:20 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: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:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Laurie FajardoTIME COMPLETED:
04:30 PM
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On 1-11-24 at 2:23pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the lead caregiver Laurie Fajardo and explained the purpose of the visit. Administrator Marcelina Lagua was made aware of visit, and gave permission for lead caregiver to sign in her absence.

LPA 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 of the facility to ensure compliance with Title 22 regulations. Facility is an adult residential facility (ARF) with a current census of 5. Facility has 4 bedrooms and 2 bathrooms for resident use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 3 ambulatory residents, 2 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved infection control plan in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 73*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 1-8-24. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOVERNOR CIRCLE CARE HOME
FACILITY NUMBER: 397002666
VISIT DATE: 01/11/2024
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LPA completed 2 resident interviews and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance and surety bond is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts monthly fire drills. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to lead caregiver Laurie Fajardo.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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