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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:18:48 PM

Document Has Been Signed on 02/07/2023 03:18 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: 3DATE:
02/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Carrie MumphreyTIME COMPLETED:
03:30 PM
NARRATIVE
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On 2-7-23 at 1:12pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a reported incident from 1-31-23. LPA met with Assistant Administrator Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was made aware of LPA's visit and purpose. LPA reviewed incident report with Assistant Administrator and conducted interview with Assistant Administrator. Based on record review and interviews conducted, it was determined that on 1-31-23 at approximately 7:30am, resident1 (R1) came downstairs and was noted by facility staff on duty to have a left black eye. Facility staff asked R1 how R1 obtained black eye. According to incident report, R1 stated the black eye was caused by falling out of bed. On the same date according to incident report, after R1 arrived at day program, Administrator spoke with R1 via telephone at which time R1 disclosed the black eye was caused by R1 being hit by another resident (R2) at facility on the morning of 1-31-23 prior to breakfast. At this time, R1 is not at facility and residing at a respite facility arranged by regional center. It is undetermined at this time if R1 will be returning to facility.

An incident report was received by licensing department on 2-1-23. Based on record review, facility has updated R1's file to reflect event described above and R1's on-going behaviors. Based on interview, it was determined that report was not sent to ombudsman and local law enforcement from facility per regulatory requirements.

As a result of today's case management visit. Citation are issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued as a result of a repeat violation within a 12-month period. 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: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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Document Has Been Signed on 02/07/2023 03:18 PM - It Cannot Be Edited


Created By: Michael Bilger On 02/07/2023 at 02:28 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: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2023
Section Cited
CCR
80061(d)

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80061 Reporting Requirements (d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1)
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Licensee will read regulation 80061(d) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will complete reporting requirements and send proof of completion to LPA by POC due date.
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This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure a report regarding suspected abuse to ombudsman and local law enforcement per regulatory guidelines. This poses a potential health, safety, and resident rights 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: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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