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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002868
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:18:05 PM

Document Has Been Signed on 03/29/2022 04:18 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:NEUBURG B.C. GUEST HOMEFACILITY NUMBER:
397002868
ADMINISTRATOR:GOULDING, JONATHANFACILITY TYPE:
735
ADDRESS:8357 NEUBOURG DRIVETELEPHONE:
(209) 952-2283
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Elizabeth Goulding, Facility ManagerTIME COMPLETED:
03:10 PM
NARRATIVE
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On 03/29/2022 at 1:15 PM, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Facility Manager, Elizabeth Goulding and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. Hot water temperature in the shared clients’ bathroom was measured at 113 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients.There is a minimum of 7-day non-perishable and 2-day perishables foods.

LPA observed smoke detectors and carbon monoxide in operating condition during inspection. Fire extinguisher was last serviced on April 05, 2021. First aid kit observed to be complete. Fire drill was last conducted 03/07/2022. LPA reviewed 3 resident files and medications. LPA reviewed 3 staff records.

LPA observed the following deficiencies:
- LPA observed kitchen mini-refrigerator unsanitary.
- LPA observed Bamboo and branches blocking the entrance way to the facility.
- LPA observed torn window screen in clients shared bedroom.

Report continues on LIC809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: NEUBURG B.C. GUEST HOME
FACILITY NUMBER: 397002868
VISIT DATE: 03/29/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/08/2022 :

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Facility Manager. A copy of report and Appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2022 04:18 PM - It Cannot Be Edited


Created By: Treana White On 03/29/2022 at 02:43 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: NEUBURG B.C. GUEST HOME
FACILITY NUMBER: 397002868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 80087(a). LPA observed unrepaired window screen, unsanitary refrigerator, and bamboo blocking entrance way which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Facility manager agreed to repair window screen, clean refrigerator, and clear passageways. Facility Manager will submit proof to CCLD by POC 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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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