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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 01/07/2025
Date Signed: 01/08/2025 08:02:26 AM

Document Has Been Signed on 01/08/2025 08:02 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
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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Maria ELena PatagTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 01/07/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a Plan of Correction visit. LPA met with caregiver Maria Elena Patag and explained the purpose of the visit. LPA asked the Caregiver Patag call the Facility Designated Administrator that CCL was present.
Shortly after, LPA spoke with Licensee Albert Gaoiran who stated that the Administrator was not able to come to the facility at the time. LPA asked who would be the representative at this time to complete this visit.
There were two other staff members present, Amalia Francisco and Felicitas Anova.
Current census is 6. The purpose of this visit was to follow up on a deficiency cited on a case management visit on 11/27/2024. On 11/27/2024 and 04/03/2024, it was found that the facility staff was sleeping on common areas within the facility, a resident was sleeping in a designated staff room and the facility was housing 2 residents in which was out of their fire clearance allowance. In addition, there was obstruction by the side gate that prohibited access to the emergency exit.
Based on interviews conducted, it was learned that the licensee has sent a new facility sketch as well as a new fire clearance to obtain 2 non-ambulatory residents, 2 ambulatory residents and 2 bedridden residents. It was learned that the Licensee has a future fire inspection on 1/09/2024 at 1:00pm.
A tour of the facility was conducted. LPA observed 6 residents. 1 resident was sleeping in bedroom #1, #2, and #3. 1 resident was sitting on the living room couch. 1 resident was eating lunch. 2 residents were in bedroom #4 sleeping. It was observed that all 4 bedrooms had 2 beds in each room. LPA did not observe any rolling beds in any of the common areas. LPA observed no obstructions to the emergency exit gate, however the gate was not self-latching.
LPA reviewed 6 resident files. Based on record review, it was learned that 3 residents are under hospice services. It was observed that all 3 residents were unable to get out of their respective bed without total assistance from the facility staff.
A technical assistance was provided today for section 87303 regarding self-closing and self-latching gates and 87202 regarding obtaining proper fire clearance.
An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907
DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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