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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005072
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:36:36 PM

Document Has Been Signed on 08/04/2022 03:36 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:SONIA'S GUEST HOME 3FACILITY NUMBER:
397005072
ADMINISTRATOR:GAPASIN, SONIAFACILITY TYPE:
740
ADDRESS:2933 ANGEL DRIVETELEPHONE:
(209) 609-9342
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nora GaleTIME COMPLETED:
04:00 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 8/4/22 at 12:45pm Licensing Program Analyst (LPA) Kevin Gould arrived at Sonia's Guest Home 3 for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Nora Gale and together conducted a tour of the home.

LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that the living room did not have an appropriate light source in the room. The living room lacked overhead lighting and only had a small desk lamp to illuminate the room which would not adequately light the room for resident and staff safety.

LPA measured the water temperature, temperature measured at 135 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed staff turn down the hot water heater but did not have enough time for the hot water to be corrected prior to LPA concluding the inspection. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, Current Administrator Certificate and Client Roster

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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 3
Document Has Been Signed on 08/04/2022 03:36 PM - It Cannot Be Edited


Created By: Kevin Gould On 08/04/2022 at 03:11 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: SONIA'S GUEST HOME 3
FACILITY NUMBER: 397005072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's testing of facility hot water temperature, the licensee did not comply with the section cited above as the hot water temperature recorded was 135 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
1
2
3
4
LPA observed staff turn down hot water heater and requested staff test the hot water prior to LPA returning to Clear the POC
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/04/2022 03:36 PM - It Cannot Be Edited


Created By: Kevin Gould On 08/04/2022 at 03:11 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: SONIA'S GUEST HOME 3
FACILITY NUMBER: 397005072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observations during the inspection, the licensee did not comply with the section cited aboveas the living room did not have adequate lighting to meet the regulations, lpa only observed a small desk light to illuminate the room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
1
2
3
4
Facility has agrred to purchase a lamp for the living room as the room lacks overhead lighting.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3