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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005730
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:54:24 PM

Document Has Been Signed on 07/14/2023 04:54 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:EPJ'S CARE HOMES #2FACILITY NUMBER:
397005730
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:311 MISSION PARK DRTELEPHONE:
(209) 477-4799
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:TIME COMPLETED:
05:00 PM
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On 7/14/23 at approximately 2pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Ernesto Patacsil and Marilyn Patacsil and explained the purpose of today's visit. Facility staff was observed to be fingerprint cleared. Ernesto Patacsil holds a current Administrator's certificate good through July 27, 2023.

The facility is licensed for 6 of which 4 may be non-ambulatory. There are currently 2 ambulatory residents and 4 non-ambulatory residents. There are two shared client rooms and 2 private client rooms. The facility has two bathrooms. LPA Jensen toured the grounds and interior of the facility. The grounds were observed to be maintained and all passages were observed to be clear of obstruction. There is outdoor furniture and shaded area available for outdoor recreational activities available. The interior of the facility was observed to be sanitary and free of odor. The thermostat was set at 75 degrees Fahrenheit and is within teh required regulatory range of 68-85 degrees Fahrenheit. The facility maintains a two day supply of perishable food and a 7 day supply of non-perishable food. Expired cans of food were observed in the pantry and discarded in the presence of the LPA. The facility maintains an adequate supply hygiene items, linens and emergency food and water.

The fire extinguisher was last serviced in March of 2023 and is in compliance. The fire extinguisher and carbon monoxide detector are combined in one unit and were determined to be in good working order. The facility conducts regular fire drills with the last one being on June 22, 2023. The Emergency Disaster Plan was reviewed and was last updated on 2/7/23 and is in compliance. The first aid kit was observed to be complete. There is emergency lighting available in the facility. All medications, toxins and knives were observed to be locked and inaccessible to residents in care. LPA Jensen checked the Medication Administration Record against the actual medication supply and determined the record keeping to be accurate. Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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: EPJ'S CARE HOMES #2
FACILITY NUMBER: 397005730
VISIT DATE: 07/14/2023
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LPA Jensen reviewed 2 staff files and found them to be complete. LPA Jensen observed to client files and found them to be complete. The inspection tool was used during the course of visit. Technical assistance was provided on the corresponding LIC 9102

Deficiencies are being cited from the California Code of Regulations. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted with Administrator Ernesto Patacsil and a copy of this report and appeal rights were handed to him.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2023 04:54 PM - It Cannot Be Edited


Created By: Maja Jensen On 07/14/2023 at 04:33 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: EPJ'S CARE HOMES #2
FACILITY NUMBER: 397005730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(7)
....All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation in a random sampling of cans in the pantry, 3 cans of food were expired,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Licensee immediately discarded the expired food product and conducted an on the spot in service training. No further plan of correction is required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023


LIC809 (FAS) - (06/04)
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