397004396-11-12-2025-27-AS-NWPN-DNCSKJ-20251112125648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004396
Report Date: 11/12/2025
Date Signed: 11/12/2025 12:57:11 PM

Document Has Been Signed on 11/12/2025 12:57 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	RIVERA'S CARE HOME II		FACILITY NUMBER:	397004396
ADMINISTRATOR/ DIRECTOR:	RIVERA, ELIZABETH M.		FACILITY TYPE:	735
ADDRESS:	3809 LADY JANE LANE		TELEPHONE:	(209) 983-9108
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 6	DATE:	11/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Mary Lou Banes		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility on 11/12/25 at 10am. LPA met with staff Mary Lou Banes, and later administrator Elizabeth Rivera by phone to explain the purpose of the visit, to conduct an annual inspection. Rivera's care home 2 is a 6 person facilty for adults aged 18-59 with a current census of 6 ambulatory residents and no restricted conditions. there are three age related exceptions for residents living in the facility. Physical inspection of the facility included but was not limited to the kitchen, bedrooms, bathrooms, exteriors, evacuation route, common areas and storage areas. The kitchen contained adequate locked storage for sharps, but food(dry goods, noodles) are kept there as well. 2 days perishable and 7 days non perishible food exists. toxics are stored locked with an adequated supply of linens. bedrooms have adequate furniture and furnishings, including matress encasements. bathrooms have functional hardware, water temperature is within 105-120*F. exteriors and common areas are clean, there's enough space for activities and no trip hazards. evacuation gate has a deadbolt that needs to be removed, but otherwise swings freely and latches closed. fire extinguisher is dated 4/9/25, smoke alarm is functional, the required posters are present except personal rights. Continued on c Page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025

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: RIVERA'S CARE HOME II	FACILITY NUMBER: 397004396
	VISIT DATE: 11/12/2025

NARRATIVE

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2 of 6 Client files were reviewed, Recent medical assessment, needs and services plan, tb screening, safegaurded property are present and up to date. signed admission agreements/house rules/client personal rights have a conflict. the house rules are restrictive to the personal rights(residents cant have visitors in the living area without staff permission, is in conflict with right 10. right to have private visitation), and an issue in an admission agreement(house rules say residents must give 30-days notice to departure, in conflict with the admission agreements 14 days to departure). LPA intervewed with clients about these violations to thier personal rights, everyone expressed they did not care about the policies as is and felt like they did not negatively impacted them. For these reasons, the LPA is going to ask that these two house rules policies be changed to conform with the personal rights from ccld without issuing the citation. a copy of the changes to the house rules should be sent to noel.wolfpetersen@dss.ca.gov by 11/19/25.

5 Staff files were reviewed, they contained a copy of the first aid/cpr, fingerprinting, tb screening, contact information, and a record of training for 20h initial topics and hours and a record of training for continuing 12h of training for topical concerns and bloodborne pathogens. all files present and up to date.

Administrator files were reviewed, including but not limited to the liability insurance, facility sketch with evacuation route, administrator certificate, fire drill record, infection control plan, emergency evacuation plan, and facility license. LPA is asking for a revision to the 610E/D to detail what transport vehicle/service will be used for emergency evacuation transport if the facility vehicle is away from the facility.

1 lunch service was observed, food seems to meet nutrition standard. 3 of 6 clients were interviewed, 3 declined to interview. general consensus statement is positive,1 staff interviewed.

Copy of the report was given to the staff, an exit interview was conducted with the administrator by phone. no citations were issued as part of this visit.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025

LIC809 (FAS) - (06/04)

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