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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:41:55 PM

Document Has Been Signed on 08/28/2024 04:41 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:		WILLIAM PUCKETTFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:William PuckettTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 8-28-24 at 1:45pm, Licensing Program Analyst (LPA) conducted a case management visit regarding physical plant operations. LPA met with Administrator William Puckett and explained the purpose of the visit. LPA conducted facility observation and conducted brief interview with Administrator and staff1 (S1). Based on interview, it was revealed that on 8-22-24, resident1 (R1) was experiencing an episode of attempting to exit facility through the sliding door. It was further determined that a locking mechanism was placed on the door to prevent it from opening. LPA observed locked used during visit which consisted of a bracket and screw designed to fit at the top of the door to prevent door from opening and obstructing a fire exit.

As a result of today's case management, citation issued under Title 22, division 6 and noted on LIC 809D. An immediate civil penalty in the amount of $500 is issued in addition to citation due to violation of Section 80072(a)(7) which created a fire hazard. An exit interview was conducted with William Puckett and a copy of this report was provided to William. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 08/28/2024 04:41 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/28/2024 at 02:01 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: INSPIRING CARE
FACILITY NUMBER: 397005738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
80072(a)(7)

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Personal Rights. (a) Except for children’s residential facilities, each client shall have personal rights which include...(7) Not to be locked in any room, building, or facility premises by day or night. This requirement was not met as evidenced by:
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Licensee will conduct staff training on personal rights and fire safety to include obstruction to fire exits. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA by 9/11/2024.
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Licensee did not ensure an unlocked sliding door in that a locking mechanism was in place on 8-22-24 which prevented door from opening. This posed an immediate 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: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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