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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004082
Report Date: 09/10/2026
Date Signed: 10/13/2026 11:11:06 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/13/2026 11:11 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/
DIRECTOR:		GAVERO, EDSON JADEFACILITY TYPE:
740
ADDRESS:334 REDWOOD AVETELEPHONE:
(209) 836-5727
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 5DATE:
09/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jesusa GaveroTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 09/10/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person, Jesusa Gavero, who was briefly interviewed at this time.
The facility designated Administrator, Edson Gavero, was contacted and unable to be present during today's annual visit.
Current census was 5 residents.
It was learned that there weren't any residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (2) residents at any given time.
It was learned that there were (3) residents diagnosed with dementia at this time. This facility does have an approved program to be able to accept and retain residents diagnosed with dementia at any given time.
Tour of the facility was conducted.
A tour of the facility kitchen area was conducted. Food storage units, refrigerator and freezer, were toured. It was observed that there was a sufficient supply of 2-day perishable food quantities available on site to meet the requirements at this time.
Pantry area was toured. It was observed that there was a sufficient supply of 7-day nonperishable food quantities available on site to meet the requirements at this time.
A review was conducted for the facility resident bedrooms at this time. It was observed that furniture and furnishings were observed to be functional and maintained in compliance at this time.
A review was conducted for the facility resident restrooms at this time. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Grab bars and non skid surfaces were observed to be present and maintained in compliance at this time.
Living areas, dining areas, and all other areas intended for resident use were toured. Furniture and
Liza King
Charlie Yang
DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/10/2026
NARRATIVE
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furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Laundry room, located prior to the entry way into the garage, was toured. It was reviewed to make sure that it was locked and made inaccessible to the residents in care.
Rooms designated as supply rooms, storage rooms, and equipment rooms were reviewed to make sure that they were locked and made inaccessible to the residents at this time.
Medication area was toured at this time. Policies and procedures in regards to the handling, dispensing, and documentation of the resident medications were discussed at this time. This facility utilized medication cups when it was time to dispense the medications to the residents.
First aid kit, located in the medication area, was observed to contain all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Coast Fire Equipment, on 06/26/2026 and found to be in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the perimeter fence, side gates, and all other exits was conducted at this time.

A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (3) facility personnel files was conducted and noted on the following LIC 859.

The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated representative at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2026 11:11 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/10/2026 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GAVERO'S CARE HOME
FACILITY NUMBER: 397004082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87303(e)(2)

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Water supplies and plumbing fixtures shall be maintained as follows:
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by
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The facility designated representative stated that the hot water heater will be turned down and the hot water temperature will be measured to make sure that it remains within the allowed range of 105-120 degrees at all times.
A statement of correction, along with proof
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residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This facility was found to be deficient as evidenced by hot water temperatures were measured at 124.3 degrees posing a immediate threat to the Health, Safety, and Personal Rights to all residents in care.
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of measured hot water temperatures, taken over the next 72 hours will be completed and submitted into CCL by the due date for review by this LPA.
Type B
09/17/2026
Section Cited
CCR87303(c)

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All window screens shall be clean and maintained in good repair.
This facility was deficient as evidenced by the observation of window screens that had rips, holes, or tears in them potentially posing a risk to the health, safety, and personal rights of residents in care.
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The facility designated representative stated that all window screens will be reviewed to make sure that they do not have any holes, rips, or tears in them. A statement of correction, along with copies of contracted services, to repair/replace the window screens will be completed and submitted into CCL by the due date for review by this LPA.
Type B
09/17/2026
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This facility was deficient as evidenced by the observation of old washer, unused bed frame, and other building materials stored on the side yard posing a potential risk to the health, safety, and personal rights of residents in care.
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The facility designated representative stated that the side yard will be cleared of all unused items to keep the area clean and clear at all times. A statement of correction, along with photos of the cleared side yard, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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