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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004764
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:14:35 PM

Document Has Been Signed on 10/01/2024 02:14 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:EPJ'S CARE HOMEFACILITY NUMBER:
397004764
ADMINISTRATOR/
DIRECTOR:
MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:6864 PERSHING AVENUETELEPHONE:
(209) 477-5247
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Myrina MarianoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on an incident, which occurred on 08/31/24 and 09/01/2024. LPA explained purpose of visit to staff.

In the incident on 8/31/24/ at 845 AM R1 insisted on leaving the facility. Direct care staff S1 tried to stop R1 from leaving. R1 hit S1 on the head and attempted to kick her. R1 told staff, she will look for her daughter and claimed her daughter is at the house behind the care home. R1 ran to the front door, opened the front door while cursing. Staff followed but R1 ran across the street, going north. R1 has since moved to another facility. The incident on 09/01/2024 at 1145 A.M. R2 was walking towards kitchen area, suddenly R1 slapped R2 on the butt and said the "B" word to R2. Both R1 and R2 become very upset and emotional, Ernesto Patacsil, JR admin/licensee calmed R2 down. While R1 became out of control and hit Marilyn Patacsil, admin on the head and twice on the arm with a closed fist. Police were called after R1 and R2 were unable to be re-directed.

Staff at the facility during this visit were not working at the facility at the time of the incidents their first day at the facility was 9/9/2024. Facility will email LPA Lewis copies of R1 and R2'S IPP, admissions agreement, Physician's report Progress notes for August and September, behavior consult notes and ISP plan by 10/04/2024. Kesha.lewis@dss.ca.gov.

This matter is still under investigation.

Exit interview conducted with administrator and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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