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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202943
Report Date: 12/22/2022
Date Signed: 12/22/2022 02:59:23 PM

Document Has Been Signed on 12/22/2022 02:59 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ESTRELLA'S CARE HOME NO. 3FACILITY NUMBER:
397202943
ADMINISTRATOR:ALLAN JOSEFACILITY TYPE:
735
ADDRESS:3837 HOLDREGE WAYTELEPHONE:
(209) 948-2013
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
12/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Melinda HarrellTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kesha Lewis and (LPM) Licensing Program Manager Liza King conducted unannounced Case Management Visit - Incident. LPA explained purpose of visit to Staff. Licensee joined 5 minutes later.

LPA asked for R1's facility file for review. R1 had been sent out to hospital on 12/1/22- and was discharged same day at approximately 11:00 PM with a diagnosis of generalized weakness. At approximately 7:00 PM on 12/2/22 R1 had no improvement and was sent back to hospital. In route to hospital R1 went in to cardiac arrest. Copy of discharge paperwork, report from hospital taken. Copy of nurse's notes, care plan, IPP, Bowel movement daily tracking sheet, 602, and resent order of medication change taken.

LPA requests a copy of the death certificate be sent via email once facility receives it. Also a copy of the updated IPP and resident roster by 1/13/22.

No deficiencies were observed or cited from the California Code of Regulations, Title 22. Documentation was taken back to regional office for review further follow up may be needed.

Exit interview conducted and a copy of report was left at facility.

Kesha.Lewis@dss.ca.gov
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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