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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005503
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:14:34 PM

Document Has Been Signed on 08/10/2023 04:14 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:MARYANN PATACSIL'S CARE HOME #2FACILITY NUMBER:
397005503
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:335 PRADO WAYTELEPHONE:
(209) 477-4915
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 3DATE:
08/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maryann MasayaTIME COMPLETED:
04:30 PM
NARRATIVE
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On 8/10/23 at approximately 1:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to address incident reports received. LPA Jensen met with Licensee Maryann Masaya and explained the purpose of today's visit.

At the time of LPA Jensen's arrival there was an Individual Program Plan (IPP) meeting being conducted with Resident 1 (R1), the Licensee and the Regional Center Service Coordinator. LPA Jensen sought permission from R1 to join the meeting and permission was granted. After the meeting LPA Jensen and the Licensee discussed incidents that occurred on 7/26/23, 7/29/23, 7/30/23 and 7/31/23 wherein R1 hit other residents.

LPA Jensen interviewed Licensee Maryann Masaya who advised that R1 was able to see a medical specialist and has had a change in medications effective 8/5/23. In addition, the facility has developed an incentive based approach for RI to refrain from physical aggression. The Licensee stated that over the past 2 days they have seen improvement with R1's behavior. The facility has staff that are on call and the on call staff will be deployed as extra support if there are triggering events.

Deficiencies are being cited form the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided to the Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 08/10/2023 04:14 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/10/2023 at 03:50 PM
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: MARYANN PATACSIL'S CARE HOME #2
FACILITY NUMBER: 397005503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
80072(a)(2)

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Personal Rights
...each client shall have personal rights which include, but are not limited to, the following:
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To be accorded safe, healthful and comfortable accommodations. This requirement was not met as evidenced by:
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The Licensee agrees to monitor and document the effectiveness of the change in medication and contact the prescribing physician if behaviors are not improving. The Licensee agrees to email the LPA the results of R1's follow up visit with the prescribing physician which is scheduled for 9/5/23 within 7 days.
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Based on incident reports received for events occuring between 7/26/23 - 7/31/23 the Licensee was unable to prevent R1 from physically attacking other 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 King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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