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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003939
Report Date: 03/10/2022
Date Signed: 03/11/2022 07:20:22 AM


Document Has Been Signed on 03/11/2022 07:20 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:OUR LADY PERPETUAL HELP CARE HOMEFACILITY NUMBER:
397003939
ADMINISTRATOR:ARCAL, ANTONIO D.FACILITY TYPE:
740
ADDRESS:1536 VALENCIA AVENUETELEPHONE:
(209) 957-5233
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Fel Arcal, Facility ManagerTIME COMPLETED:
03:10 PM
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LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by Maria Felcisim Arcal (Fel) who informed Administrator Antionio the LPA' s visit. Mr. Arcal was not avaiable to meet with LPA and LPA discussed the purpose of the visit over the phobne. LPA explained the purpose of the visit and Fel accompanied LPA on the facility inspection.

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5 clients and 5 bedrooms and 3 bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Medications and toxins noted to be locked to residents 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 stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: OUR LADY PERPETUAL HELP CARE HOME
FACILITY NUMBER: 397003939
VISIT DATE: 03/10/2022
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The facility common areas were clean and furnished. Smoke and carbon detectors were tested and are operational and in good repair. Fire extinguishers were serviced in June 2021 and are in compliance. All staff on-site have current fingerprint clearances. Carbon monoxide detector was on-site, tested and is operational. LPA wspoke to several residents and thier family members who were at the home

LPA received a current LIC 500 and LIC 309 .

Per California Code of Regulations, Title 22 no deficiencies were observed during this visit. Exit interview was held and a report was issued Ms Arcal.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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