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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:20:31 PM

Document Has Been Signed on 04/28/2022 04:20 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 CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Carrie MumphreyTIME COMPLETED:
04:20 PM
NARRATIVE
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On 4-28-22 at 3:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to complaint control #27-AS-20220405083355. LPA met with assistant administrator Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett made aware of LPA's visit. During a complaint visit and investigation for #27-AS-20220405083355, it was identified through this complaint investigation that Resident1 (R1) has a history of falls. Appraisal Needs and Service plan dated 2-15-22 for R1 was reviewed as well as incident reports for R1. Based on record review it was determined that R1 sustained falls on 2-16-22 and 4-12-22. Additionally, it was revealed through record review that appraisal needs and service plan for R1 is not updated to reflect specific interventions for fall preventions.

Deficiencies are cited as a result of today's case management visit. An exit interview was conducted with Carrie Mumphrey and a copy of this report was left with Carrie. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 04:20 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/28/2022 at 03:37 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: INSPIRING CARE
FACILITY NUMBER: 397005738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2022
Section Cited
CCR
80068.3(a)

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Modifications to needs and service plan. (a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy...This requirement is not met as evidenced by:
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Licensee will update R1s appraisal needs and service plan and submit to LPA by POC due date.

Licensee will develop a plan to ensure appraisal needs and service plans are updated as appropriate. Licensee to submit plan to LPA by POC due date.
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Based on record review, Licensee did not ensure R1s appraisal needs and service plan was updated to reflect fall prevention interventions after sustaining falls on 2-16-22 and 4-12-22. This poses a potential health and safety risk to 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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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