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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 07/14/2021
Date Signed: 07/14/2021 02:44:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/14/2021 02:44 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: 4DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Geline ArtuzTIME COMPLETED:
03:00 PM
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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 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and 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 3 staff files, including criminal record clearances. S1 left the facility during the inspection. There is no documents for S1 and LPA was unable to identify S1. The staff on-site did not have a contact number or any other information for S1.There were other staff with limited or no information in the staff files. 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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 07/14/2021 02:44 PM - It Cannot Be Edited


Created By: Albert Johnson On 07/14/2021 at 12:21 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: STETSON COURT LIVING
FACILITY NUMBER: 397005195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited
CCR
87606(f)(1)

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Care of Bedridden Residents. To accept or retain a bedridden person, a facility shall ensure the following: The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons.
This requirement is not met as evidenced by:
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Facility shall immediately notify the fire district that they have a bedridden resident. Facility shall ensure there is staffing sufficient to accommodate transfer residents.
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Record review, interviews, and observation. Facility failed to obtain proper fire clearance for (R1). R1 is unable to turn or assist with ADLs This poses and immediate health and safety risk to residents in care.
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Facility shall update the facility's Plan of Operation to address how the facility intends to meet the needs of bedridden residents in the home. R1 will have his LIC602 updated to reflect his current ambulatory status.
Type A
07/15/2021
Section Cited
CCR87463(c)

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87463 Reappraisals. (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first
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Licensee agrees to complete updated Reappraisal and Needs and Service plan for Residents R1 and provide to CCL by FAX by 7/15/21.
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This requirement is not met as evidenced by: Based on record review, the licensee failed to ensure that annual reappraisals were done for R1 last assessment was done in 2015, which poses a health risk to residents in care.
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The facility will also provide a schedule for R1 to have has finger nails and toe nails trimmed.
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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2021 02:44 PM - It Cannot Be Edited


Created By: Albert Johnson On 07/14/2021 at 02:00 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: STETSON COURT LIVING
FACILITY NUMBER: 397005195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
87412(b)(2)

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87412(b)(2) Personnel Records
Health screening documents as specified in Section 87411(e). This requirement is not met as evidenced by: oberservation and records review LPA obtained information that the health screening for staff S1 was not done.
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Licensee shall submit proof of correction by POC due date.
Type B
07/21/2021
Section Cited
CCR
80075(f)

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80075(f) Health Related Services. Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross.

Expired First Aid and CPR for S3 proof in file.
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Administrator shall call a First AID vendor and requested a New Card or send by email proof. Administrator will send a copy of First Aid card to LPA. FAX (916) 263-4744
Type B
07/21/2021
Section Cited
CCR87411(c)

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Personnel Requirements – General. All staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. S1 and S2 file is missing orientation documentation
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Licensee shall submit a written plan on how she is going to ensure all staff will have the required training before and during employment. 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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021


LIC809 (FAS) - (06/04)
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