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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005130
Report Date: 11/10/2021
Date Signed: 11/10/2021 04:54:12 PM

Document Has Been Signed on 11/10/2021 04:54 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:TELECARE SAN JOAQUIN CRISIS RESIDENTIAL SERVICESFACILITY NUMBER:
397005130
ADMINISTRATOR:RAKSMEY ROEUM-CASTLEMANFACILITY TYPE:
772
ADDRESS:5634 JEREMY WAYTELEPHONE:
(209) 888-4969
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 6DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Raksmey Roeum-CastlemanTIME COMPLETED:
05:00 PM
NARRATIVE
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On 11-10-21 at 1:32pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Raksmey Roeum-Castleman and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed social rehabilitation facility with a current census of 6. Facility has a dining area off the kitchen and separate living and TV room for clients. There are 4 bedrooms upstairs and 1 bedroom downstairs. There is also 1 staff office upstairs and 1 staff office downstairs. LPA also conducted the infection control domain tool.
The facility has a COVID Mitigation plan in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead. The facility is able to designate and dedicate a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 131.4*F in the bathroom and room temperature reads 72*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 10-11-21. Facility has an emergency food and water kit. No obstructions to fire exits noted. Six staffing charts were reviewed and found to be in compliance at this time.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held with Raksmey-Roeum-Castleman and a report was given to Administrator Raksmey Roeum-Castleman
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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 11/10/2021 04:54 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/10/2021 at 04:02 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: TELECARE SAN JOAQUIN CRISIS RESIDENTIAL SERVICES
FACILITY NUMBER: 397005130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Water temperature in client used bathroom measured at 131.4*F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2021
Plan of Correction
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Licensee will adjust water temperature appropriately to maintain temperature between 105*F and 120*F and send photo proof to LPA by POC due date.

Licensee will develop a plan to regularly monitor facility water temperature and submit plan to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
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