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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005056
Report Date: 05/18/2023
Date Signed: 05/18/2023 12:59:05 PM

Document Has Been Signed on 05/18/2023 12:59 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: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:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Magdalene KizerTIME COMPLETED:
01:15 PM
NARRATIVE
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On 5-18-23 at 10:23am Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Magdalene Kizer and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a adult residential care facility with a current census of 6. Facility has 4 bedrooms and 2 bathrooms. Three bedrooms are for resident use; one bedroom is for staff use.. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 ambulatory residents, 0 non ambulatory residents, 0 hospice, and 0 bedridden.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4-27-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 resident files and 3 staffing files were reviewed for regulatory compliance.

{Cont. on LIC 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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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: KIZER GUEST HOME #1
FACILITY NUMBER: 397005056
VISIT DATE: 05/18/2023
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One of three staff files reviewed did not contain evidence of health screening per regulatory requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 2 resident interviews and 1 staff interview. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility does not contain any bodies of water. LPA observed personal rights posted. Facility does not have a current updated disaster plan. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500. A copy of LIC 610D was requested as part of a plan of correction.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. Exit interview was held and a report was given to Administrator Magdalene Kizer. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2023 12:59 PM - It Cannot Be Edited


Created By: Michael Bilger On 05/18/2023 at 12:11 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: KIZER GUEST HOME #1
FACILITY NUMBER: 397005056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 3 staffing files reviewed. Staff3 (S3) chart did not contain a health screening form. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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Licensee will submit a completed, updated health screening form for S3 to LPA by POC due date.

Licensee will read regulation 80066(a)(10) and submit a signed declaration of understanding to LPA by POC due date
Type B
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility does not possess an updated diaster plan meeting the regulatory requirements above. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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LIcensee will submit a completed and updated diaster plan (LIC 610D) to LPA by POC due date
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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


LIC809 (FAS) - (06/04)
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