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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004012
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:00:13 PM


Document Has Been Signed on 08/30/2023 04:00 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:RIVER FOUNTAINS OF LODIFACILITY NUMBER:
397004012
ADMINISTRATOR:REBECCA COBBFACILITY TYPE:
740
ADDRESS:311 WEST TURNER ROADTELEPHONE:
(209) 334-3763
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:80CENSUS: 63DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rebecca Cobb, AdministratorTIME COMPLETED:
03:00 PM
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On 08/30/23, Licensing Program Analyst (LPA), Renee Campbell arrived at the facility at 8:30 am to conduct a Required - 1 year visits. LPA Campbell met with Rebecca Cobb, Administrator and discussed the purpose of the visit. In the hallway near the dining room, LPA Campbell identified a poster size See Something Say Something sign. A poster size display of the Long Term Care Ombudsman's(LTCO) information with the number for the San Joaquin County Ombudsman's phone and fax number was also observed.

The facility is licensed for a capacity of 80 non-ambulatory residents age 60 and above. The facility also has an approved hospice waiver for 10 residents. There is no bedridden approval. There are 63 residents of which, 1 receives hospice care services and there are no bedridden residents at this time.

The temperature inside the facility was 70 degrees Fahrenheit which is within the required range of 68-85 degrees Fahrenheit. The hot water temperature was measured at 117 degrees Fahrenheit in one bathroom and at 120 degrees Fahrenheit in a bathroom at the other side of the building. Both measurements are within the required range of 105 to 120 degrees Fahrenheit. LPA observed fire extinguishers that were fully charged that had been last checked on 06/01/23. Smoke and carbon monoxide detectors were also identified in the facility. A Fire Safety drill report was reviewed as well. Central air was functioning in the facility. LPA observed enough food to support residents and staff for 2 days and enough non-perishables for 7 days.

LPA Campbell observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, antiseptic solution and gauze.
(cont LIC809-C)





SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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: RIVER FOUNTAINS OF LODI
FACILITY NUMBER: 397004012
VISIT DATE: 08/30/2023
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Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Personnel Report (LIC500)
Administrator Certificate


Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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