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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202945
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:16:59 PM

Document Has Been Signed on 08/21/2024 12:16 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:CASA DE OROFACILITY NUMBER:
397202945
ADMINISTRATOR/
DIRECTOR:		VAN DE POL, NELLENFACILITY TYPE:
735
ADDRESS:6717 LORRAINE AVENUETELEPHONE:
(209) 957-3907
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
08/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:17 AM
MET WITH:Nellen Van De PolTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 8/21/2024 at 10:17pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding physical plant operations. LPA met with Administrator Nellen Van De Pol and explained the purpose of the visit. During today's visit, LPA conducted brief interview with Administrator, resident1 (R1), and R2. LPA also conducted facility observation. Based on observation it was determined that hallway bathroom toilet is not properly flushing. Additionally, toilet in master room is flushing and accompanied by a loud piercing sound requiring attention. It was further discovered through interviews that hallways toilet overflowed at least once.

As a result of today's case, citation issued under Title 22, Division 6. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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 08/21/2024 12:16 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/21/2024 at 11:19 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: CASA DE ORO
FACILITY NUMBER: 397202945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2024
Section Cited
CCR
80087(a)

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Buidlings and Grounds (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. This requirement was not met as evidenced by:
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Licensee notified plumber during LPA's visit to address needed repair.

LPA observed plumber repairing toilet on site. Licensee to send video proof of repair to LPA by POC due date.
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Based on observation and interview, hallway bathroom toilet is not flushing properly, This poses 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: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
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