397005719-8-29-2023-27-AS-MBIR-CV6SHD-20230829135323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005719
Report Date: 08/29/2023
Date Signed: 08/29/2023 01:53:32 PM

Document Has Been Signed on 08/29/2023 01:53 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:	DIGNA'S CARE HOME #1		FACILITY NUMBER:	397005719
ADMINISTRATOR:	CABRERA, DIGNA		FACILITY TYPE:	735
ADDRESS:	2955 CHRISTINA AVE		TELEPHONE:	(209) 598-7588
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY: 6		CENSUS: 6	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Roselilie Castillo		TIME COMPLETED:	02:00 PM

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	On 8-29-23 at 10:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with the assistant administrator Roselilie Castillo and explained the purpose of the visit. Administrator Digna Cabrera was not present and gave permission for Roselilie to sign in her absence. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an adult residential facility with a current census of 6. Facility has 6 bedrooms and 2 bathrooms for resident use. A separate room is designated for staff use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 1 ambulatory resident, 5 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved infection control plan in place. Facilities current fire clearance and license state facility may only have up to 2 non-ambulatory residents. Water temperature reads 105F to 120F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 6-6-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. {Cont. on LIC 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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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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: DIGNA'S CARE HOME #1	FACILITY NUMBER: 397005719
	VISIT DATE: 08/29/2023

NARRATIVE

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During this inspection 5 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 1 resident interview and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts monthly fire drills. Facility has 2 residents with bedrails with physician orders in place. Resident's personal and incidental records (P&I) were reviewed with facility staff present for accuracy. P&I records were determined to be accurate at this time. LPA requested an updated copy of LIC 308, LIC 500, resident roster, current liability insurance form, current and proposed facility sketch for bedridden capacity update, and updated LIC 200.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. An immediate civil penalty in the amount of $500 is issued as a result of fire clearance deficiency. An exit interview was held and a report was given to Assisted Administrator Roslillie Castillo. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 01:53 PM - It Cannot Be Edited

Created By: Michael Bilger On 08/29/2023 at 01:23 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: DIGNA'S CARE HOME #1	FACILITY NUMBER: 397005719
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

80020. Fire Clearance. (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that 5 of 6 residents in care are now non-ambulatory without an updated approved fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2023
	Plan of Correction
1 2 3 4	Licensee will submit a current and proposed facility sketch indicating rooms to be approved for bedridden, and a updated LIC 200 form to LPA by POC due date. Licensee will read regulation 80020(a) and submit a signed declaration of understanding to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Michael Bilger

LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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