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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004082
Report Date: 08/18/2022
Date Signed: 08/18/2022 03:57:43 PM


Document Has Been Signed on 08/18/2022 03:57 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
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: 6DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jesusa GaveroTIME COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced Required 1-year inspection visit. LPA Pascua met with Facility Designated Representative, Jesusa Gavero and stated the purpose of today's visit. Staff was asked to call the Facility Designated Administrator at this time to let them know that CCL was present. There was one other staff member present, Yolanda Tosco. Administrator holds a current certificate and expires on, 09/06/2022.
This facility has a hospice waiver for 2 and a dementia program on file.
The current census was 6.
A tour of the facility was conducted.
Fire extinguisher located by the dining room is valid until 11/23/2022.
The facility has a main entrance COVID screening point. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily.
The kitchen area was toured. LPA observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen.
LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
The exterior of the physical plant was toured with no hazards present. One exit gate was inspected and the perimeter fence was observed to be stable.
The common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of 3 resident rooms were conducted. Resident furniture was observed to be sufficient to meet resident needs at this time. A staff room was also toured.
A linen closet was located in the hallway and presented a sufficient amount of linen to adequately supply and meet the needs of the residents at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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


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
VISIT DATE: 08/18/2022
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A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
A tour of the garage was conducted. Additional storage for supplies and files were stored in cabinets. Additional perishable food supply was identified.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Representative.

Exit interview.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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