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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002666
Report Date: 01/12/2022
Date Signed: 01/12/2022 11:58:37 AM

Document Has Been Signed on 01/12/2022 11:58 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: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:
01/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Marcelina LaguaTIME COMPLETED:
12:04 PM
NARRATIVE
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On 1/12/22 at 9:51am Licensing Program Analyst (LPA), Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Marcelina Lagua 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 facility with a current census of 5. Facility has 4 bedrooms, 2 shared and 2 private. Facility also has 2 bathrooms for client use. There is a dining area off the kitchen and a formal living/tv area.
The facility has an approved COVID Mitigation plan LIC 808 form in place.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 112.4*F in the bathroom and room temperature reads 74*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 1/5/22. Facility has an emergency food and water kit and 30-day supply of PPE. Fire drills are conducted quarterly. Records for Staff1 (S1), S2, S3, S4, S5, S6, S7 reviewed. Based on record review S5's first aid/cpr card was missing from file. All staff vaccination records verified. Fingerprint clearances were verified for all staff.
Per California Code of Regulations, Title 22, division 6 deficiencies were observed during this visit. Exit interview was held with Marcelina Lagua and a report was given to Marcelina. Appeal rights provided
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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 01/12/2022 11:58 AM - It Cannot Be Edited


Created By: Michael Bilger On 01/12/2022 at 11:10 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: GOVERNOR CIRCLE CARE HOME
FACILITY NUMBER: 397002666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2022
Section Cited
CCR
80075(f)

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80075 Health Related Services (f)Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not as evidenced by:
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Licensee will submit proof of dates of first aid instruction for S5 to LPA by POC due date.

Licensee to submit proof of completed first aid instruction to LPA by POC due date.
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Based on record review of S5, licensee did not ensure documented evidence of updated first aid instruction. This poses a potential health and safety risk to clients 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: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022


LIC809 (FAS) - (06/04)
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