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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 06/02/2022
Date Signed: 06/28/2022 10:56:44 AM

Document Has Been Signed on 06/28/2022 10:56 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:
06/02/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Geline ArtuzTIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Albert Johnson made an unannounced Safety check to the facility to verify correction of citation issued during the Annual inspection on 03/28/2022 and to follow-up on the health and safety checks.

During the tour of the facility LPA observed debris on the side of the house and the files for all the residents including staff are not at the facility. LPA was able to confirm that Aida Fontanilla is not associated to this facility as of today's date.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed during this visit.

LPA will return to review files and complete the safety inspection/ plan of correction visit. Exit interview held with Staff.

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SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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 06/28/2022 10:56 AM - It Cannot Be Edited


Created By: Albert Johnson On 06/02/2022 at 11:10 AM
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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2022
Section Cited
CCR
80087(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 the removed debris on the side of the house in the fire lane. The pictures shall be sent by POC 6/15/22.
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This requirement is not met as evidenced by:
LPA observed debris on the side of the house. This poses a potential safety risk to the residents in care.
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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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
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