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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 02/21/2023
Date Signed: 02/23/2023 02:34:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/23/2023 02:34 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:STETSON COURT LIVINGFACILITY NUMBER:
397005195
ADMINISTRATOR:GAOIRAN, CHRISTIANFACILITY TYPE:
740
ADDRESS:3913 STETSON COURTTELEPHONE:
(408) 876-9445
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Geline ArtuzTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Geline Artuz and explained the purpose of the visit.

LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, medication rooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 128.5 degrees Fahrenheit in resident's bathroom sink, which is not within the required range of 105 to 120 degrees.

Fire extinguishers is out of compliance (purchase date was 1/22/22) smoke detectors and carbon monoxide detector were in compliance with fire safety. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 2 staff files, including criminal record clearances. LPA observed during the file review 3 outdated service plans for (R1, R2 and R3) and R1 also had an outdated Physician's report. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed during this visit. Exit interview held with Administrator and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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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Document Has Been Signed on 02/23/2023 02:34 PM - It Cannot Be Edited

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: STETSON COURT LIVING
FACILITY NUMBER: 397005195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2023
Section Cited

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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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The facility will arrange for a company to service the extinguishers and will provide proof to CCL that the fire extinguishers have been serviced or a new one purchased and are in compliance.
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This requirement is not met as evidenced by:Based on observation the licensee did not comply with the section cited above as the fire extinguisher were last purchased on Januaryof 2022 which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/22/2023
Section Cited

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Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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The facility shall develop and implement a policy regarding fire drill and earthquake drill practices and procedures that include conducting fire drills at least once every three months on each shift and shall include,
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LPA was able to determine the last disaster drill was conducted on 12/30/2021 this poses an immediate safety risk.
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at a minimum, all direct care staff. Send copy of updated policy and fire drill log by POC 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/23/2023 02:34 PM - It Cannot Be Edited

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: STETSON COURT LIVING
FACILITY NUMBER: 397005195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited

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Care of Persons with Dementia
Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.
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All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated
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LPA observed that R1 diagnosed with dementia didn't have an updated LIC 602.
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LIC 602. Statement of correction, with copy of updated LIC 602, to be completed and submitted into CCL by the due date.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
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