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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002923
Report Date: 10/29/2021
Date Signed: 10/29/2021 02:46:21 PM

COMPREHENSIVE INSPECTION
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:REMOLONA FAMILY GUEST HOMEFACILITY NUMBER:
397002923
ADMINISTRATOR:NORA REMOLONAFACILITY TYPE:
740
ADDRESS:360 BUTTON AVENUETELEPHONE:
(209) 823-9122
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:15CENSUS: 13DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Nora RemolonaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Administrator Nora Remolona Administrator holds current certificate that expires 11/01/2022.

LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 130.5 degrees Fahrenheit in resident bathroom sink of the left side of the building, which is not within the required range of 105 to 120 degrees, right side of the building resident bathroom hot water temperature was measured at 108.5 degrees Fahrenheit, which is within the required range of 105 to 120 degrees. Last fire drill was conducted on 08/17/2021.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident's files, LPA identified 5 residents on hospice this was confirmed by Administrator. LPA reviewed 3 staff files including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and appeal rights discussed.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2021
Section Cited

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80088(e)(1) Fixtures, Furniture Equipment and Supplies. Hot water delivered to fixtures used by clients shall attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
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Based off of LPA and S1 observation the hot water when measured at 130.5 This poses immediate risk to residents 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021
LIC809 (FAS) - (06/04)
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