397005617-10-21-2021-27-AS-AJON-C7ZP4M-20211021105923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005617
Report Date: 10/21/2021
Date Signed: 10/21/2021 11:00:14 AM

Document Has Been Signed on 10/21/2021 11:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	WALTERS RESIDENTIAL HOME CARE		FACILITY NUMBER:	397005617
ADMINISTRATOR:	MOSES WALTERS SR.		FACILITY TYPE:	735
ADDRESS:	2746 ABRUZZI COURT		TELEPHONE:	(510) 688-3552
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 4	DATE:	10/21/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Administrator, Moses Walters SR. and Tanneh Koayen		TIME COMPLETED:	11:04 AM

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An Informal Conference was conducted today at the Sacramento Regional Office via Facetime. Present for the meeting was Administrator, Moses Walters SR. and Tanneh Koayen , Licensing Program Manager, Stephenie Doub and the writer of this report Licensing Program Analyst, Albert Johnson .

The purpose of the informal conference was to address the facility’s compliance issues. The Department has concerns stemming from site inspections on multiple dates during this current year “2021”.

The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could then lead to referral to the Department's legal division for possible revocation of license. Issues discussed during the meeting were:

85077(a) – 85077 Personal Services. (a) Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing. (Resident received a burn while in care.) As a result of this citation a civil penalty determination is pending by the department. Once civil penalty assessment has been determined, an LPA will return at a future date to assess the civil penalty.

Continued

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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: WALTERS RESIDENTIAL HOME CARE	FACILITY NUMBER: 397005617
	VISIT DATE: 10/21/2021

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80065(i)(1-3) - Personnel Requirements Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record. (Staff was not cleared to work at this facility and was not associated to the facility.)

80078(a) - 80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. (Staff did not provide adequate supervision to resident's in care.)

In an effort to support the facility maintaining substantial compliance with health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns.

Plan to address compliance concerns:

The facility provided training on personal care including regular water temperature checks.

In-service training was conducted to address AWOLs, medications and behaviors of residents with strategies to mitigate or prevent antecedents and encourage positive replacement behaviors.

The department will provide additional case management visits.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of C1’s sustaining a burn (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Exit interview conducted and copy of report provided to facility representative

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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