397003946-5-14-2021-27-AS-TWHE-C2ZPWA-20210514114024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397003946
Report Date: 05/14/2021
Date Signed: 05/14/2021 03:54:21 PM

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:	ALCOR GUEST HOME II		FACILITY NUMBER:	397003946
ADMINISTRATOR:	POIER, CORAZON		FACILITY TYPE:	740
ADDRESS:	5555 PATTI LYNN WAY		TELEPHONE:	(209) 478-9804
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY:	6	CENSUS: 4	DATE:	05/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Corazon Poier, Licensee		TIME COMPLETED:	11:50 AM

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	On 05/14/2021 at 8:20am, Licensing Program Analyst (LPA) T. White spoke with Licensee, Corazon Poier regarding facility risk assessment questions. Licensee confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:45am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Licensee 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 residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on February 17, 2021. Emergency Disaster Plan was last posted on 10/14/2020. First aid kit was observed to be complete. Fire drill was last conducted on 05/05/2021. LPA reviewed mitigation plan with Administrator. - On 05/14/202, LPA T. White observed three medication bottles ( Losaratan, Meditone, Aspirin) in the unlocked kitchen drawer accessible to residents in care. Report continues on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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: ALCOR GUEST HOME II	FACILITY NUMBER: 397003946
	VISIT DATE: 05/14/2021

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/21/2021:

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

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

LPA had printer issues and will submit report and appeal rights via email. Exit interview conducted with Administrator.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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: ALCOR GUEST HOME II	FACILITY NUMBER: 397003946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 87465(h)(2). LPA observed three bottles of medications accessible in unlocked kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/14/2021
	Plan of Correction
1 2 3 4	Licensee removed medication from kitchen drawer and locked it away. Licensee agreed to conduct an in-service training regarding medication with staff members. Licensee agreed to submit proof to CCLD by 05/21/2021.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

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