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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005280
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:19:40 PM

Document Has Been Signed on 04/27/2023 02:19 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:RIVERA'S CARE HOMEFACILITY NUMBER:
397005280
ADMINISTRATOR:RIVERA, ELIZABETH M.FACILITY TYPE:
735
ADDRESS:372 WEST DELHI STREETTELEPHONE:
(209) 467-3761
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 3DATE:
04/27/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Marilous BanesTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson made an unannounced visit to this facility to conduct an Annual visit.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are two bedrooms and one bathroom for clients. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathroom was in need of repair, there is a hole at the bottom left corner and the hot water temperature was observed and measured to be 131.5 degrees not within the required limits.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non- perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to clients. LPA observe the backyard of the facility to be free of clutter and debris and there appeared to be no potential safety hazards to the clients. Smoke detectors are operational and care home also has a carbon monoxide detector. Fire extinguishers and first aid kit are maintained and ready for emergency use. Care home also conducts monthly fire/disaster drills. During the tour LPA observed that the garage door opener is broken and in need of repair.

LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA checked resident records for completeness and accuracy. Care home staff also has criminal record clearances and current first aid training on file.

Deficiencies cited during this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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 04/27/2023 02:19 PM - It Cannot Be Edited


Created By: Albert Johnson On 04/27/2023 at 11:12 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: RIVERA'S CARE HOME
FACILITY NUMBER: 397005280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Administrator lowered the thermostat during the tour and agreed to test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA.
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LPA tested hot water at 131 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a health and safety risk to resident in care.
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Type B
05/12/2023
Section Cited
CCR80087(a)

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(a) 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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The Licensee will have these items repaired by the POC date of 5/12/23. The Licensee will submit the repair invoices to confirm completion of the needed repairs to the department by fax or email.
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The bathroom was in need of repair, there is a hole at the bottom left corner by the toilet and garage door opener is broken and in need of repair.
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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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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