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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005245
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:33:48 PM


Document Has Been Signed on 05/09/2023 12:33 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:A GOOD SAMARITAN HOME-BARBADOSFACILITY NUMBER:
397005245
ADMINISTRATOR:DEMESA, WILLIAM B.FACILITY TYPE:
740
ADDRESS:5315 BARBADOS CIRCLETELEPHONE:
(209) 451-0656
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 0DATE:
05/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:William DemesaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced case management visit at facility on 5-9-23 at 9:59am for the proceeding of the facility closure. LPA met with Licensee William Demesa and explained the purpose of this visit. Based on interview conducted, Licensee has closed facility as of 4-1-23 after resident1 (R1) and R2 were transferred to other facilities. Additionally, based on interview, facility had a census of 2 since November of 2022. Upon further record review and interview, it was determined that Licensee provided notice of closure to residents and their responsible parties verbally and via text, but did not produce a written notice, nor send a copy of notice to licensing department per regulatory requirements.

LPA observed interior/exterior of the facility, including front and back yards, living room, activity room, dining room, kitchen, bathrooms, and all bedrooms. LPA observed that there were no residents at the facility.

LPA retrieved original license and informed Administrator that the facility will be closed in the system as of 5-11-23. A copy of this report was left with Administrator.

Citations are issued as a result of today's case management. An exit interview was conducted with William Demesa and a copy of this report was let with William. Appeal rights provided.

Link to survey for Facility Closure provided to William Demesa

www.surveymonkey.com/r/facilityclosure
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/09/2023 12:33 PM - 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: A GOOD SAMARITAN HOME-BARBADOS
FACILITY NUMBER: 397005245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

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Eviction Procedures. (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). (5) Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.
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Licensee will read section 87224(a)(5)(A) and submit a signed declaration of understanding to LPA by POC due date.
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This requirement was not met as evidenced by: Based on interview and record review, licensee did not provide resident1 (R1) and R2 with a written 60-day notice due to license forfeiture per regulatory requirements. This posed a potential health and safety risk to residents in care.
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Type B
05/19/2023
Section Cited

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Eviction Procedures. (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by:
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Licensee will read regulation 87224(f) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Licensee initiated an eviction and transfer process for R1 and R2 and did not send a written report to licensing agency within regulatory time frames. This posed a potential health and safety risk to 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/09/2023 12:33 PM - 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: A GOOD SAMARITAN HOME-BARBADOS
FACILITY NUMBER: 397005245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

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Administrator-Qualifications. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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Licensee will review regulation 87224 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Licensee did not exercise knowledge of eviction procedures in that licensee initiated an eviction and transfer of R1 and R2 without proper notification .This posed a potential health and safety risk to 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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