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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004082
Report Date: 08/19/2024
Date Signed: 08/20/2024 07:14:09 AM


Document Has Been Signed on 08/20/2024 07:14 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jesusa Gavero TIME COMPLETED:
12:00 PM
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On 08/19/2024, 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. There was two other staff members present at the facility, Cynthia Sison and Joyce Victa. It was learned that the Facility Designated Administrator (FDA), was unable to come to the facility at this time. LPA continued the visit with FDR Gavero.
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 5. A brief interview with FDR Gavero was conducted.
LPA reviewed 5 resident files were reviewed. 5 out of 5 resident files were complete and up to date.
LPA reviewed 3 staff files were reviewed. 3 out 3 staff files were complete and up to date. The Facility Designated Administrator 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 Coast Fire Equipment on 03/10/2024. Smoke alarms and carbon monoxide detectors were present and in compliance. Last emergency safety drill was conducted with residents on 07/08/2024.
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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GAVERO'S CARE HOME
FACILITY NUMBER: 397004082
VISIT DATE: 08/19/2024
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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 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.
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 610e

A technical violation is being provided for 87303(e)(3).
Based on the observations based during the visit, there are no deficiencies were observed or cited during this annual visit.

An exit interview was conducted and a copy of this report was provided to the Facility at the end of this visit.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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