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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 06/28/2024
Date Signed: 06/28/2024 12:22:44 PM

Document Has Been Signed on 06/28/2024 12:22 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR/
DIRECTOR:		PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Porschia Collins TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management visit following up on a complaint visit on 6/24/2024. LPA explained purpose of visit to staff.

LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with staff. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed to contain no foul odors. Fire extinguisher was full charged and dated 08-14-23. Room temperature was 76*F. Smoke alarms and carbon detectors are functioning properly. Only one staff was available as 1 staff called out for the day and one was running late.


Per California Code of Regulations, Title 22 deficiencies were observed and are being cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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 06/28/2024 12:22 PM - It Cannot Be Edited


Created By: Kesha Lewis On 06/28/2024 at 10:51 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: INSPIRING CARE
FACILITY NUMBER: 397005738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2024
Section Cited
CCR
80087(a)

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a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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The Administrator will submit a plan with a timeline to the Department outlining how they will come in to compliance withthe above listed regulation. By COB on 7-1-2024.
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Based on LPA Lewis observation of the porch area the railing is extreamly loose and seem as if it willl fall at anytime. The licensee did not comply with the section cited above in 1 counts which poses/posed a immediate health, safety or personal rights risk to persons in care.
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Type B
06/28/2024
Section Cited
CCR85072(b)(9)

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(b) The licensee shall insure that each client is accorded the following personal rights. (9)To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.
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Staff gave R1 the phone while LPA Lewis was at the facility. LPA made sure R1 had kept possion of their phone. No futhur action is needed at this time.
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Based on LPA Lewis's interview with R1, R1 stated that the staff lock her phone up. When LPA Lewis asked for R1's Phone is was locked in a safe. The licensee did not comply with the section cited above in 1 counts which poses/posed a potential health, safety or personal rights risk to persons 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:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
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