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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003939
Report Date: 05/16/2023
Date Signed: 05/16/2023 08:05:38 PM


Document Has Been Signed on 05/16/2023 08:05 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
SACRAMENTO AC/SC, 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:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Maria ArcalTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Kesha Lewis at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by Staff member and Administrator joined 15 minutes later. LPA were screened upon entry for COVID precautions. LPA explained the purpose of the visit to Administrator. Administrator's Certificate # 6019316740 Expires 07/25/2024.

LPA and Administrator 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. 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. Chemicals and medications noted to be locked to residents in care. LPA also conducted the infection control domain tool.

Hot water temperature was measured at 105 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

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.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: OUR LADY PERPETUAL HELP CARE HOME
FACILITY NUMBER: 397003939
VISIT DATE: 05/16/2023
NARRATIVE
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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.

LPA observed, fire extinguishers inspected on 08/30/2022 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility after review of staff records LPA observed that only one (1) Staff member had a valid CPR and first aid certificate and it was not the staff member working at the time.



LPA reviewed three (3) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.


Administrator Maria Arcal will stay at the facility until another staff member has valid CPR.

The following deficiencies are being cited Per California Code of Regulations, Title 22, Division 6, Chapter 8. See 809D page.

Exit interview held with staff and copies of reports left at conclusion of visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 05/16/2023 08:05 PM - 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
SACRAMENTO AC/SC, 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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87923(a)(1)

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a) All direct care staff and the facility manager shall have first aid training from persons qualified by agencies including, but not limited to, the American Red Cross.
(1) A copy of the current First Aid card shall be maintained in the personnel record.
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Facility agrees updated all first aid cards. In additions, facility agrees to e-mail new CPR certification certificates. Administrator will stay on site until another staff member has valid training.

Kesha.Lewis@dss.ca.gov
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This requirement is not met as evidence by observation. LPA reviewed 3 staff personnel files and only 1 staff member had a valid training. this was not the staff member working at the time. This poses an imitate health and safety risk for 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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