397005245-5-21-2021-27-AS-MBIR-C392BG-20210521171507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005245
Report Date: 05/19/2021
Date Signed: 05/21/2021 05:16:50 PM

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:	A GOOD SAMARITAN HOME-BARBADOS		FACILITY NUMBER:	397005245
ADMINISTRATOR:	DEMESA, WILLIAM B.		FACILITY TYPE:	740
ADDRESS:	5315 BARBADOS CIRCLE		TELEPHONE:	(209) 406-6610
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	6	CENSUS: 3	DATE:	05/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	William Demesa, Administrator		TIME COMPLETED:	11:05 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Bilger arrived to conduct an unannounced Annual inspection on 5/19/21. LPA was greeted by S1 and informed her of the purpose of the visit. LPA met with William Demesa, Administrator who arrived shortly thereafter, and was informed of the purpose of the visit. Administrator was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. Facility is licensed for 6 beds with a fire clearance for 3 ambulatory, 3 non-ambulatory, 2 hospice, and 1 bedridden residents. Current census is 3. There are no residents on hospice or receiving bedridden care at this time. All 3 residents are under the ALW program. Administrator certificate is current and expires on 2/5/23. 2 staff charts were revviewed. All necessary components were present and updated including required training. 3 resident charts were reviewed. All necessary components were present and updated including admission agreement. LPA toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures. Smoke alarms and carbon monoxide detectors were tested and were operable. LPA toured resident rooms which contained all appropriate furnishings and accommodations. LPA also inspected the living room and family room areas. 7 days of non-perishable, and 2 days of perishable food items are in place. Fire extinguisher was charged and (cont. on 809C)

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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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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: A GOOD SAMARITAN HOME-BARBADOS	FACILITY NUMBER: 397005245
	VISIT DATE: 05/19/2021

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last serviced on 9/2020. Sharp objects and toxins were inaccessible to residents in care. All staff are fingerprint cleared and associated to work in the facility at this time. LPA observed adequate amount of linens available for residents. Medications were locked and secured. facility temperatuer measured at 70 degrees F. Hot water temperature measured at 108.1 degrees in kitchen area and 107.8 degrees in bathroom. First aid kit was accessible and stocked appropriately.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, LIC 309 were requested to be submitted to Licensing within 30 days.

As a result of this inspection, no deficiencies were cited today.

Exit interview was conducted with Administrator and a copy of report and appeal rights were given at the conclusion of the visit.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC809 (FAS) - (06/04)

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