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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004082
Report Date: 09/07/2021
Date Signed: 09/08/2021 04:11:14 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:GAVERO'S CARE HOMEFACILITY NUMBER:
397004082
ADMINISTRATOR:GAVERO, EDSON JADEFACILITY TYPE:
740
ADDRESS:334 REDWOOD AVETELEPHONE:
(209) 836-5727
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 4DATE:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Jesusa & Edson Gavero, AdministratorsTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced Annual/ Infection Control visit on this date. LPA met with Jesusa & Edson Gavero (AD), Administrators
LPA and AD inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPA observed cabinet under sink in kitchen locked. LPA observed sharps and centrally stored medications locked in pantry closet.

Hot water temperature was measured in residents' bathroom with the Administrator at 119.5 degrees which is in required range of 105 to 120 degrees. LPA observed there was a Carbon Monoxide/ Fire monitors in facility.
LPA verified the last FireDrill was conducted July 2021. Fire extinguisher maintained on 9/27/20.
LPA reviewed 3 staff and 4 resident files. Resident emergency contact complete. LPA observed all staff files complete. Administrator Certificate valid until 9/6/2022.
All persons in facility fully vaccinated. LPA observed resident practicing social distancing. LPA observed 30 days PPE supply.

LPA observed there was no non-skid pad in resident's bathroom. LPA observed in one of the residents bedrooms 2 hospital beds and a hoyer lift.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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: GAVERO'S CARE HOME
FACILITY NUMBER: 397004082
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2021
Section Cited

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Postural Supports (a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require ... documentation ... This requirement was not met as evidence by:
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The administrator failed obtain a written order from physician for use of bedrails. LPA observed bedrails and hospital bed in residents bedrooms. This poses an immediate health risk to residents in care.
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Type B
09/18/2021
Section Cited

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Buildings and Grounds - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This requirement is not met as evidenced by:
LPA observed both shower rooms need non-skid mats/materials installed. This poses a potential safety risk to the 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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