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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 11/19/2024
Date Signed: 11/19/2024 11:02:15 AM

Document Has Been Signed on 11/19/2024 11:02 AM - 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: 0DATE:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:William PuckettTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 11/19/24 at 10;15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding regulatory compliance. LPA met with Licensee William Puckett and explained the purpose of the visit. LPA reviewed documentation related to complaint #27-AS-20240805090404 and # 27-AS-20240823100640. LPA also conducted interviews with Administrator. Based on interviews and record reviews, it was determined that on 4-5-24, a facility staff member received a restraining order to maintain distance from a resident1 (R1) living at the facility. This event was not reported to licensing department. Additionally, during July 2024, R2 engaged in an absence without leave (AWOL) and insufficient staffing was a contributing factor. It was determined that a scheduled one-on-one staff member was late for her shift and Administrator did not ensure an appropriate staffing solution at that time.

As a result of today’s case management, citation is issued under Title 22, Division 6 and noted on 809D. An exit interview was conducted with Licensee and a copy of this report was provided to Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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 11/19/2024 11:02 AM - It Cannot Be Edited


Created By: Michael Bilger On 11/19/2024 at 10:33 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: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
80064(a)(3)

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Administrator-Qualifications and Duties. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee will read regulation 80064 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Administrator did not comply with reporting requirements and personnel requirements per regulations. This posed 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: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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