397005738-10-24-2022-27-AS-MBIR-CKHTF4-20221024144054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:42:30 PM

Document Has Been Signed on 10/24/2022 02:42 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:	INSPIRING CARE		FACILITY NUMBER:	397005738
ADMINISTRATOR:	PUCKETT, VICTORIA		FACILITY TYPE:	735
ADDRESS:	2488 NATHANIEL STREET		TELEPHONE:	(209) 951-2405
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY: 5		CENSUS: 4	DATE:	10/24/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	William Puckett		TIME COMPLETED:	01:30 PM

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On 10-24-22 at 1:00pm, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Licensee William Puckett, Assistant Administrator Carrie Mumphrey, Ombudsman Kathryn Thomas, and Regional Center representatives Stephanie Medina and Katina Richison. Topics in this meeting included the following: (1) Needs and Service plan, (2) Personal Rights, (3) Client Records, (4) Reporting Requirements, (5) Building and Grounds, (6) Administrator Qualifications, (7) Food Services, (8) COVID precautions, and (9) Care and Supervision.

LPA Bilger and LPM King discussed with licensee and assistant administrator the following citations and the associated plans of correction going forward:

On 3-9-22 a citation was issued under 80070(a)(b)(10) Client records due to incomplete medication log sheets. Training was conducted by licensee and a sign off sheet per shift as been developed and in use.

On 4-28-22 a citation was issued under 80068.3(a) Modifications to needs and service plan due to needs and service plan not updated after a recent fall episode involving a resident. Check sheet to review needs and service plan with incident reports has been developed by Licensee and currently in use to address needs to change needs and service plan, individual program plan (IPP) and/or Individualized Service Plan (ISP)

On 6-14-22 multiple citations were issued under the following:

80076(18) Food services due to inappropriately labeled food and unsecured food storage,

80064(a(3) Administrator Qualifications and Duties due to not ensuring the following of COVID precautions,

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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: INSPIRING CARE	FACILITY NUMBER: 397005738
	VISIT DATE: 10/24/2022

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80072(a)(7) Personal Rights due to locking of the front entry door from the inside,

80078(a) Building and Grounds due to torn carpeting and a loose banister,

Health and Safety Code (HSC) 1550(c) Licenses or Administrator certificate due to conduct inimical regarding a lack of 30-day supply of personal protective equipment (PPE)

80078(a)(b)(10) Client records due to incomplete medication log sheets for two residents (repeat violation and civil penalty issued), and

80072(a)(2) Personal rights due to a disorganized medication storage closet

Licensee stated staff is now stabilized and trained as upon hire. Licensee is reviewing the quality assurance checklists at least 3 to 4 times per week.

On 7-28-22 a citation was issued under 80072(a)(1) Personal Rights due to a staff member using profanity towards a resident. Licensee confirmed staff member no longer working at the facility and staff training was completed regarding personal rights.

On 7-13-22 a citation was issued under 80078(a) Responsibility for Providing Care and Supervision due to a resident AWOL on 6-24-22 and facility unaware of whereabouts as a result

On 7-13-22 a citation was issued under 80061(d) Reporting Requirements due to a suspected abuse not reported to licensing as per regulatory requirements.

Licensee has Increased supervision for night shift 10-4 and 11-7. In addition, there has been a medication change per psychiatrist, and resident is now sleeping through the night. Resident has also signed an agreement to decrease cigarettes and an incentive program has been developed to help resident with smoking plan. Licensee stated facility was unaware of alleged sexual assault of resident until learning about the even through a police report. Licensee stated that staff is have received updated mandated reporting requirement training.

The department is requesting the following to be submitted by the Licensee by 10-25-22:

1. Updated LIC 500 to reflect Administrator’s hours on duty

2. Updated LIC 308 as changes occur

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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: INSPIRING CARE	FACILITY NUMBER: 397005738
	VISIT DATE: 10/24/2022

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The department is requiring Administrator be on duty at facility for no less than 40 hours per week. Department shall conduct quarterly visits to ensure compliance with above and all other Title 22 requirements. Quarterly visits shall consist of, but not be limited to: (1) Review of client files, (2) Review of medication administration records and check list, (3) Inspection of food storage areas, and (4) Physical Plant inspections. LPM and LPA notified Administrator that future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and a non-compliance conference to discuss further potential administrative action.

An exit interview was conducted with William Puckett and a copy of the port was emailed to William with request for return with signature.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC809 (FAS) - (06/04)

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