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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004764
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:02:09 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/17/2022 02:02 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:EPJ'S CARE HOMEFACILITY NUMBER:
397004764
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:6864 PERSHING AVENUETELEPHONE:
(209) 477-5247
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Febe GarvidaTIME COMPLETED:
12:00 PM
NARRATIVE
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On 8/17/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1-year annual visit. LPA Jensen met with care giver and explained the purpose of today's visit.

The facility is a single story facility that has a gated front yard. There is a single designated entrance with COVID signs posted outside. LPA was greeted by care staff and screened, including a temperature check upon arrival. LPA Jensen toured the facility including but not limited to grounds, kitchen, 3 bedrooms, 1 staff room, dining room, living room, 2 bathrooms, garage and laundry room. The facility was sanitary and equipped with adequate lighting.

The facility sketch was posted and accurately reflects the premises. The temperature was 74 degrees and is within the required regulatory range of 68-85 degrees. There were 2 first aid kits observed that were complete. Emergency lighting was on hand. The hallways were equipped with night lights. A 30 day supply of personal protective equipment was observed. Carbon monoxide detectors were tested and observed to be in working order. The fire extinguisher was last serviced in March of 2022 and is in compliance.

The kitchen was observed to have at least two day of perishable food and 7 days of non-perishable food. There was fresh fruit observed accessible to residents in care. Knives were observed to be locked and inaccessible to residents in care. Toxins and cleaning supplies were observed to be locked and inaccessible to residents in care. 3 kitchen cabinets next to dining room, where utensils are stored, were observed to be broken and missing knobs.
The water temperature measured 118 degrees which is within the regulatory range of 105-120 degrees.
The facility has an adequate supply of linens. The resident bedrooms were observed to be equipped with all necessary furniture. The window screens were in good repair. The laundry room contained a washer and dryer in working order and had toxins locked and inaccessible to residents.
Continued on LIC 809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EPJ'S CARE HOME
FACILITY NUMBER: 397004764
VISIT DATE: 08/17/2022
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Continued from LIC 809...
A hose was laid out across a cement walkway in the backyard posing a tripping hazed. The backyard was landscaped and had seating for guests on a large covered patio.

There are currently 2 live in staff members at the facility. 2 of 2 staff files were reviewed and were determined to be complete with all necessary documentation and certifications.

LPA Jensen interacted with several residents and interviewed 2 of 6 residents. Deficiencies are being cited today from the California Code of Regulations Title 22, Division 6.

An exit interview was conducted with Febe Garvida and a copy of this report and appeal rights were emailed to Administrator Maryann Patacsil.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/17/2022 02:02 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/17/2022 at 01:03 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: EPJ'S CARE HOME
FACILITY NUMBER: 397004764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
80087(a)

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80087 Buildings 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 was not met as evidenced by:
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Licensee agrees to repair kitchen cabinets and send photo evidence by email to maja.jensen@dss.ca.gov. The hose was immediately put away by care staff and does not require a plan of correction.
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Based on LPA's observation and photographs taken there are three broken cabinet drawers in the litchen next to the dining room. This poses a potential health, safety and personal risk to residents 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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