<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003939
Report Date: 08/20/2022
Date Signed: 08/22/2022 09:13:07 AM


Document Has Been Signed on 08/22/2022 09:13 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: 6DATE:
08/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Maria ArcalTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt made an unannounced visit on this day at approximately 02:00 p.m. for the purpose of conducting an abbreviated annual inspection. An annual inspection was previously conducted on March 10, 2022. LPA Hurt met with Administrator, Maria Arca, observed the following

• Covid precautions being followed
• Interior and exterior of the plant
• (7) seven day non-perishable and (2) day perishable supply of food
• Medications were observed to be locked up
• LPA observed Fire extinguishers are not fully charged.
• Smoke detectors all operational.
• Hot water temperature measured 106 degrees.
• All employees requiring background checks are cleared.

The following deficiencies are being cited Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit.

An exit interview was held, and a copy of the report was left with Administrator, Maria Arcal.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2022
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


Document Has Been Signed on 08/22/2022 09:13 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203(a)
87203
Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation], the licensee did not comply with the section cited above in 2 out of 2 fire extinguishers are outdated as of 06/2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2022
Plan of Correction
1
2
3
4
Facility staff will update both fire extinguishers and send proof to LPA by 08/21/2022 POC date .
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2