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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004396
Report Date: 08/07/2023
Date Signed: 08/08/2023 11:05:21 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/08/2023 11:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:RIVERA'S CARE HOME IIFACILITY NUMBER:
397004396
ADMINISTRATOR:RIVERA, ELIZABETH M.FACILITY TYPE:
735
ADDRESS:3809 LADY JANE LANETELEPHONE:
(209) 983-9108
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Carmelita QuerosTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Carmelita and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 140 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident and 1 staff files, including criminal record clearances. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Fire drill was conducted on 7/2023

Per the Title 22, Division 6 of California Code of Regulations. Deficiencies were cited during today's inspection.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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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Document Has Been Signed on 08/08/2023 11:05 AM - It Cannot Be Edited


Created By: Albert Johnson On 08/07/2023 at 01:59 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RIVERA'S CARE HOME II
FACILITY NUMBER: 397004396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2023
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Staff lowered the thermostat during the tour. The facility will test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA by 8/12/2023
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LPA tested hot water at 140 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a health and safety risk to resident in care.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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