397004913-11-4-2021-27-AS-TWHE-C8EVA2-20211103161512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004913
Report Date: 11/03/2021
Date Signed: 11/04/2021 10:21:35 AM

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 HOME II		FACILITY NUMBER:	397004913
ADMINISTRATOR:	VELASQUEZ, ANGELICA & GENE		FACILITY TYPE:	740
ADDRESS:	2815 MIRASOL LANE		TELEPHONE:	(209) 955-1033
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY:	6	CENSUS: 4	DATE:	11/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Facility Staff, Josie LLarenas		TIME COMPLETED:	04:30 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	On 11/03/2021 around 12: 50 PM, Licensing Program Analyst (LPA) T. White spoke with facility staff regarding facility risk assessment questions. Facility staff confirmed no staff or clients have experienced symptoms within the last 10 days. At 2:25 pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with facility staff, Josie LLarenas and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.2 and 111.8 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on March 09, 2021. First aid kit was observed to be complete. LPA observed completed mitigation plan. LPA reviewed 3 residents files and 3 staff files. - LPA observed fire drill last conducted November 2020. - LPA observed Staff #3 is cleared, but not associated to facility. Report continues on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: ZOSING CARE HOME II	FACILITY NUMBER: 397004913
	VISIT DATE: 11/03/2021

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/12/2021:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with facility staff. Exit interview conducted and Appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: ZOSING CARE HOME II	FACILITY NUMBER: 397004913
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and documentation, the licensee did not comply with the section cited above in 87355 (e)(2). LPA observed Staff #3 is not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2021
	Plan of Correction
1 2 3 4	Facility agreed to associate Staff #3 to facility and submit proof to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: ZOSING CARE HOME II	FACILITY NUMBER: 397004913
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and documentation, the licensee did not comply with the section cited above in1569.65(c). LPA observation facility last conducted fire drill November 2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2021
	Plan of Correction
1 2 3 4	Facility agreed to conduct a fire drill and submit proof to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC809 (FAS) - (06/04)

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