397004082-9-19-2023-27-AS-APAA-CVTQDC-20230919120427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004082
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:05:01 PM

Document Has Been Signed on 09/19/2023 12:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GAVERO'S CARE HOME		FACILITY NUMBER:	397004082
ADMINISTRATOR:	GAVERO, EDSON JADE		FACILITY TYPE:	740
ADDRESS:	334 REDWOOD AVE		TELEPHONE:	(209) 836-5727
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Jesusa Gavero		TIME COMPLETED:	12:00 PM

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 09/19/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived to the facility unannounced to conduct an annual visit. LPA was greeted by Facility Designated Representative, Jesusa Gavero and explained the purpose of the visit. Shortly after, LPA met with the Facility Designated Administrator, Edson Gavero. There was one other staff member present at the facility, This facility is licensed to serve and retain 6 residents who are 60 and over of which may be all non-ambulatory. This facility also holds a dementia plan on file. Current Census was 6. A brief interview with FDA Gavero was conducted. It was learned that there is currently one resident on hospice services and 2 residents who are non-ambulatory. LPA reviewed 3 resident files and 3 staff files. All resident and staff files were current and up to date. The FDA has a current administrator certificate #6017960740 and expires on 09/06/2024. A tour of the facility was conducted. There are currently two fire extinguishers located throughout the facility and have been serviced by GBFE on 03/15/2023. Smoke alarms and carbon monoxide detectors were present and in compliance. 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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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: 09/19/2023

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
26
27
28
29
30
31
32

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.
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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2