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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004913
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:05:12 PM


Document Has Been Signed on 10/05/2023 12:05 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:ZOSING CARE HOME IIFACILITY NUMBER:
397004913
ADMINISTRATOR:VELASQUEZ, ANGELICA & GENEFACILITY TYPE:
740
ADDRESS:2815 MIRASOL LANETELEPHONE:
(209) 955-1033
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Angelica VelasquezTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 10/05/2023 at 10:40 AM. LPA Martinez met with Angelica Velasquez and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator certificate expired on 06/20/2023, and Angelica Velasquez has submitted their renewal application to the Department on May 28, 2023. The facility is licensed for 6 non-ambulatory residents. There are currently 6 residents who reside at this facility. The facility has an approved hospice waiver for 2.

LPA Martinez toured the facility with Angelica Velasquez on 10/05/2023 at 11:30 AM.

LPA Martinez reviewed two staff files and two client files. The facility files are maintained. LPA Martinez reviewed two medication administration records, and the records are complete and maintained. The facility has an infection control plan and a natural disaster plan. The facility has a first aid kit. The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. The exterior emergency exit gate is in good repair. Resident bedrooms and bathrooms are furnished and in good repair. The facility common areas are in good repair and furnished. The facility has a public telephone, and has an area for activities. The facility temperature measured at 77 degrees, and the facility water temperature measured at 109 degrees. The facility has an adequate food supply, and the kitchen is sanitary and clean. Resident bedrooms and bathrooms are furnished and sanitary. The exterior of the facility is clear of debris, and the facility has a covered patio for resident use. Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. There were no deficiencies cited at this time. An exit interview was conducted, and copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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