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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 04/03/2024
Date Signed: 04/03/2024 11:52:09 AM


Document Has Been Signed on 04/03/2024 11:52 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
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: 6DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:RONILO HUERTAS - DIRECT CARE STAFFTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted a unannounced Required 1 year Inspection Visit. LPA met with direct care staff and explained the purpose of visit. Administrator's Certificate expires 12/18/2024.

LPA and direct care staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, and outside backyard. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 111.9 degrees Fahrenheit which is within the required range of 105 to 120 degrees. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

Fire extinguishers were last inspected on 7/24/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 3/25/2024. Staff have been sleeping on a roll away bed in common areas which is not on fire clearance. Facility sketch shows bedroom #3 as staff room, but a resident in presently in #3 bedroom.
LPA reviewed four resident files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA requested the following updated documents for community care licensing to be submitted via email by April 8, 2024: Facility Sketch, Fire Clearance, LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance. ruth.wallace@dss.ca.gov
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.
Exit interview conducted with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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 04/03/2024 11:52 AM - 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interviewing staff, the licensee did not comply with the section cited above in staff have been sleeping in common areas on roll away beds. The facility sketch shows bedroom #3 as a staff room, but a resident is living in that room. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Licensee agrees to submit a plan of correction by 4/4/24 stating how the facility will comply with community care licensing regulations regarding fire clearance. Licensee agrees to submit via email to LPA. ruth.wallace@dss.ca.gov
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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/03/2024 11:52 AM - 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(e)(2)(B)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (2) The person shall meet any of the following practical experience or licensure requirements: (B) Two years of full-time experience, or the equivalent, within the last four years, as an administrator for a residential care facility for the elderly, during which time the individual has acted in substantial compliance with applicable regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in staff have been sleeping on roll away beds in common areas and facility sketch shows bedroom #3 as a staff room. A resident in living in #3 bedroom. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Licensee agrees to submit letter stating how administrator will be in compliance with applicable regulations regarding the requirements for fire clearance and qualifications for administrator. Licensee agrees to submit via email to LPA. ruth.wallace@dss.ca.gov
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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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