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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004396
Report Date: 11/08/2024
Date Signed: 11/08/2024 02:29:33 PM

Document Has Been Signed on 11/08/2024 02:29 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:RIVERA'S CARE HOME IIFACILITY NUMBER:
397004396
ADMINISTRATOR/
DIRECTOR:		RIVERA, ELIZABETH M.FACILITY TYPE:
735
ADDRESS:3809 LADY JANE LANETELEPHONE:
(209) 983-9108
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Abigail RiveraTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 11/8/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a required one year annual visit. LPA Jensen spoke with the Licensee by telephone and met with Abigail Rivera and explained the purpose of today's visit.

LPA Jensen toured the exterior. The front yard was maintained and all paths were free of obstruction. The back yard has a wooden deck and covered patio with furniture that includes a cloth sofa with a hole in the upholstery that is approximately 12 inches by 2 inches. There is a tin can that has been re-purposed as an ashtray next to sofa. Multiple clients were observed smoking in this area. There is also a cloth sofa on the ground in the backyard with more than 50 burn holes in it that appear to be from cigarettes and a plastic Foldgers coffee tub next to it that is being used as another ashtray. The side of the wooden deck has a wood pile and several cigarette butts littered on the ground next to a wooden fence. There is a shed in the backyard that is locked. The care staff that were present stated that they do not have the keys to the shed. LPA Jensen reached the Administrator by telephone and Elizabeth Rivera advised that the key is currently with her and she is unable to bring it to the facility on this day. The Administrator stated that the shed only contains her own personal belongings. The side yard was cordoned off with a broken screen and had debris piled up including wood piles, broken children's bicycles, exercise equipment, lawn mower, rubber belts, dust pan, plastic crates and chairs amongst other items that appeared inoperable. A deficiency is being cited as the these observations present a safety risk for fire. Please refer to LIC 809D.

LPA Jensen toured the interior. The thermostat was set at 72 degrees for the comfort of the residents. There are night lights available in the hallway. The fire extinguisher was last serviced in February of 2024 and is in compliance. The carbon monoxide detector and smoke detector were tested and determined to be in good working order. The first aid kit is complete. Continued on LIC 809C...
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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: RIVERA'S CARE HOME II
FACILITY NUMBER: 397004396
VISIT DATE: 11/08/2024
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LPA Jensen toured the client bedrooms. The bedrooms are double occupancy and do not contain any chairs. Technical assistance was provided. The mattresses have mattress protectors and clean linens. 2 of 3 bedrooms have TV's that sit on tall, tall narrow filing cabinets. A recommendation is being made to secure the TV's to the wall for safety. The facility maintains an adequate supply of linens. LPA Jensen observed all required postings on the wall. Individual client behavioral health appointment information is also posted for all residents and should be removed from public view to respect each persons right to privacy.

LPA Jensen inspected the kitchen and observed knives, medications and toxins are kept secured and inaccessible to residents. There is an adequate supply of perishable food and non-perishable food including fresh fruit and vegetables. LPA Jensen observed lunch service which consisted of a hamburger and juice. LPA Jensen was advised by a client that the facility charges $1 for soda. The care provider confirmed this statement to be true. LPA advised the Licensee that the facility cannot charge residents more than what the item was purchased for and that this practice should stop effective immediately. Alternative options include letting residents purchase soda at the store or providing it at no cost.

LPA Jensen reviewed 3 resident files and 3 staff files. The resident files reviewed were determined to be complete. The staff files were also complete. This facility is licensed for a maximum capacity of 6 adults 59 years old and under. The facility is currently home to 6 residents, 3 of which are over 60 years of age. The Licensee requested an age exception which was denied on 9/27/24, in part for a lack of supporting documentation. LPA Jensen is providing technical assistance and requesting supporting documentation, as outlined in the LIC 9102 that references California Code of Regulations (CCR) 85068.4. Age exception supporting documentation is being requested by 11/15/24.

Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 02:29 PM - It Cannot Be Edited


Created By: Maja Jensen On 11/08/2024 at 01:34 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: RIVERA'S CARE HOME II
FACILITY NUMBER: 397004396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of cigarette butts on the ground next to wood piles and upholstered sofas with burn holes the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The Licensee agrees to remove all debris from the side yard and by the storage shed. The Licensee also agrees to remove the upholstered sofas or cover them with a fire resistant cover and to use ashtrays that have fire suppressant features. Photos will be sent to the department by email by the Plan of Correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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