397005130-2-7-2025-27-AS-CYAG-DDNNL9-20250207093311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005130
Report Date: 02/06/2025
Date Signed: 02/07/2025 09:33:25 AM

Document Has Been Signed on 02/07/2025 09:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	TELECARE SAN JOAQUIN CRISIS RESIDENTIAL SERVICES		FACILITY NUMBER:	397005130
ADMINISTRATOR/ DIRECTOR:	RAKSMEY ROEUM-CASTLEMAN		FACILITY TYPE:	772
ADDRESS:	5634 JEREMY WAY		TELEPHONE:	(209) 888-4969
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY: 6		CENSUS: 5	DATE:	02/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Raksmey Tiano		TIME VISIT/ INSPECTION COMPLETED:	01:30 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	Unannounced annual visit made out to this facility on 02/06/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff persons, (Vannika Chay, Thuy Huynh, and Malissa Anderson), who were briefly interviewed at this time. This LPA requested that the facility staff go ahead and contact the facility designated Administrator, Raksmey Tiano, to inform her that CCL was present at this time. The facility designated Administrator, Raksmey Tiano, arrived later to this facility while this LPA was conducting this annual visit. Current census was 5 residents. A tour of the facility was conducted alongside Thuy Huynh and Raksmey Tiano. A tour of the kitchen was conducted. Drawers and cabinets were reviewed. Knives and other sharp instruments were properly stored in the pantry area at this time to make them inaccessible to the residents at all times. A review of the pantry area was conducted. A review of the facility food storage units was conducted. A review of the facility 2-day perishable and 7-day nonperishable food supply was conducted at this time. A tour of the garage area was conducted. It was learned that this area was used to store facility designated items such as additional clothes, holiday decorations, and additional food storage units. A review of the dining area, living area, and all other areas designated for resident use was conducted. Furniture and furnishings were observed to be sufficient and found to be in compliance at this time. First floor resident bedroom for resident use was toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Adjacent first floor resident restroom was toured. Hot water temperature was measured to make sure that it was within the allowed range of 105-120 degrees at all times. A tour of the second floor resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time. Second floor office room was toured. It was learned that this room was also used as the medication room to

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TELECARE SAN JOAQUIN CRISIS RESIDENTIAL SERVICES	FACILITY NUMBER: 397005130
	VISIT DATE: 02/06/2025

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
26
27
28
29
30
31
32

properly store the resident medications at this time.
Laundry room was toured. Detergents, cleaning supplies, and bleach were properly stored and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility on both floors, were observed to have been recently checked and updated on 01/31/2024 by the local fire extinguisher company, Armor Fire, at this time.
A review of the exterior grounds was conducted. A review of the facility perimeter fence, side gate, and all other exits was conducted and observed to be in compliance at this time.

A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility staff files was conducted and noted on the following LIC 859.

This LPA requested that this facility update and submit the following forms and documents into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/07/2025 09:33 AM - It Cannot Be Edited

Created By: Charlie Yang On 02/06/2025 at 01:38 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TELECARE SAN JOAQUIN CRISIS RESIDENTIAL SERVICES	FACILITY NUMBER: 397005130
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81087(a)

Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the carpet throughout this facility on both floors needed to be vacuumed, cleaned and treated to remove signs of wear and stains which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2025
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the carpet, throughout this facility, will be scheduled by a third party vendor to be cleaned, vacuumed, and treated. A statement of correction, along with a copy of the receipt for services rendered, will be completed and submitted into CCL by the due date. Photos will be taken of the common areas and resident bedrooms and submitted as well.

Type B

Section Cited

CCR

80088(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 observation, the licensee did not comply with the section cited above in that several window screens were in need of repair/replacement to address holes and bent screen frames which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2025
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all window screens will be reviewed and updated to address any holes, tears, and bent frames by repair or replacement. A statement of correction, along with receipts for all repaired/replaced window screens, will be completed and submitted into CCL by the 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:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3