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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004511
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:09:29 PM


Document Has Been Signed on 01/10/2023 01:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ZOSING CARE HOMEFACILITY NUMBER:
397004511
ADMINISTRATOR:ANGELICA VELASQUEZFACILITY TYPE:
740
ADDRESS:2777 WISTERIA LANETELEPHONE:
(916) 955-1033
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 5DATE:
01/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Angelica Velasquez - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Inspection Visit. LPA met with administrator and explained the purpose of the visit. Administrator certificate #6003830740 expires on 07/07/2023.

This facility is a single story building licensed to serve six (6) non-ambulatory residents and a hospice waiver for 2 residents. LPA and administrator toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were last serviced 3/28/2022. Smoke and carbon monoxide detectors are in compliance with fire safety. Thermostat observed at (74) degrees Fahrenheit.
LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed three (3) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

LPA requested the following forms to be submitted via email by February 6, 2023:
LIC 308, LIC 610-D, Liability insurance Certificate, and Administrator Certificate.

No deficiencies cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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