<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005056
Report Date: 05/31/2022
Date Signed: 05/31/2022 11:40:31 AM

Document Has Been Signed on 05/31/2022 11:40 AM - 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:KIZER GUEST HOME #1FACILITY NUMBER:
397005056
ADMINISTRATOR:KIZER, MAGDALENEFACILITY TYPE:
735
ADDRESS:8357 KILTIE WAYTELEPHONE:
(209) 401-5014
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Magdalene Kizer - Licensee/AdministratorTIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection visit. LPA met with the administrator and explained the purpose of the visit. Administrator Certificate Expires 03/12/2024

LPA Wallace and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Resident bathroom flooring needs to be replaced, due to tears in flooring and patio screen door needs to be replaced. LPA also conducted the infection control domain tool. The hot water measured 107.4*F which is within the required range of 105-120*F. LPA observed the facility to have adequate food supply. Smoke and carbon detectors were in good repair. Fire extinguisher expires 3/30/2023.
.
The facility submitted a LIC 808 mitigation plan, which has been approved. Upon entry LPA observed screening for COVID precautions including temperature check. Upon entry LPA observed the facility to have COVID - 19 informational, and social distancing signs posted throughout the facility, and on the front door. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Per California Code of Regulations, Title 22, Division 6 deficiencies were cited during this visit.

Exit interview was held and a copies of reports were given to Administrator. Appeal rights were given to Administrator.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/31/2022 11:40 AM - It Cannot Be Edited


Created By: Ruth Wallace On 05/31/2022 at 11:28 AM
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: KIZER GUEST HOME #1
FACILITY NUMBER: 397005056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in patio screen door is bent and needs to be replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
1
2
3
4
Licensee agrees to replace patio screen door by June 30, 2022 and submit to LPA via email receipt of replaced patio screen door.
ruth.wallace@dss.ca.gov
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in resident bathroom flooring has tears and needs to be replaced for safety of residents. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2022
Plan of Correction
1
2
3
4
Licensee agrees to replace bathroom flooring by July 31, 2022 and submit to LPA via email receipt and pictures of replaced bathroom flooring.
ruth.wallace@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2