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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 11/27/2024
Date Signed: 12/06/2024 04:23:29 PM

Document Has Been Signed on 12/06/2024 04:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STETSON COURT LIVINGFACILITY NUMBER:
397005195
ADMINISTRATOR/
DIRECTOR:		GAOIRAN, CHRISTIANFACILITY TYPE:
740
ADDRESS:3913 STETSON COURTTELEPHONE:
(408) 876-9445
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
11/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Care Staff Concepion Castas TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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LPA Jason Lund arrived unannounced to conduct an health and safety check. LPA met with care staff Concepion Castas. LPA Lund spoke with Licensee/Administrator Albert Gaoiran over the phone and explained the reason for the visit. Census:6

LPA Lund observed five residents at the facility and one resident at a doctor’s appointment. LPA Lund observed that there were three residents on hospice out of the six residents. All three residents are bedridden and get out of bed with out the help of staff. Resident (R1) was put on hospice on 9/3/2023 and is bedridden. Resident (R2) was put on hospice on 10/15/2024. Resident (R3) was put on hospice on 6/13/2023. All three residents are bedridden and get out of bed with the help of staff. The facility license dated 4/30/2013 states that facility is licensed for 6 nonambulatory residents and hospice for four. The license doesn’t state the facility can have bedridden residents. LPA Lund observed debris on the side of the facility and the emergency exit gate doesn’t have a latch and needs to be fixed.

LPA requested the following updated documents for community care licensing to be submitted via email. LIC 500 - Personnel Report, Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, see 809-D's for deficiencies observed or cited today. If the deficiencies are not corrected by the noted due date civil penalties may be assessed. LPA Lund called LPA Lund spoke with Licensee/Administrator Albert Gaoiran over the phone.

LPA Lund amended the visit on 12/6/2024
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
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 12/06/2024 04:19 PM - It Cannot Be Edited


Created By: Jason Lund On 11/27/2024 at 12:03 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: STETSON COURT LIVING
FACILITY NUMBER: 397005195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2024
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
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Administrator shall submit a new fire clearance by 12/2/2024 or issue 30 day notices to residents to LPA Lund.
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This requirement is not met as evidenced by: . LPA Lund observed that there were three residents on hospice out of the six residents. All three residents are bedridden and get out of bed with out the help of staff.
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Type B
12/10/2024
Section Cited
CCR80087(a)

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Buildings and Grounds - 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.
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Administrator shall submit pictures of debris on the side of the facility and the emergency exit gate doesn’t have a latch and needs to be fixed. The pictures shall be sent by POC 12/10/24.
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LPA Lund observed debris on the side of the facility and the emergency exit gate doesn’t have a latch and needs to be fixed.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2024


LIC809 (FAS) - (06/04)
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