<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202947
Report Date: 06/06/2022
Date Signed: 06/21/2022 08:03:12 AM

Document Has Been Signed on 06/21/2022 08:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NEW HOPE GUEST HOME - TRETHEWAYFACILITY NUMBER:
397202947
ADMINISTRATOR:FELIX, ROBERT A.FACILITY TYPE:
735
ADDRESS:17451 NO. TRETHEWAY ROADTELEPHONE:
(209) 333-9322
CITY:LOCKEFORDSTATE: CAZIP CODE:
95237
CAPACITY: 6CENSUS: 4DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Robert Felix, LicenseeTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/06/2022 at 10:50 am, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Licensee, Robert Felix and Administrator, Joan Talaroc. LPA explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on February 07, 2022. Mitigation plan observed to be complete and located at the faciltiy. First aid kit was observed to be complete. Fire drill was last conducted on May 04, 2022. LPA reviewed 4 client files and 3 staff record files.

LPA observed the following deficiencies:
- LPA observed open bottle of alcohol located on kitchen counter accessible to clients in care.
- LPA observed Resident #4 (R4) does not have Physician Report and TB Test on file.
- LPA observed 2 of 4 clients does not have current Individual Program Plan (IPP) on file.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Licensee. Appeal rights and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 06/21/2022 08:03 AM - It Cannot Be Edited


Created By: Treana White On 06/06/2022 at 12:55 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME - TRETHEWAY
FACILITY NUMBER: 397202947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds:

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation the licensee did not comply with the section cited above in 80087(g). LPA observed open bottle of alcohol located on kitchen cabinet accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
1
2
3
4
LPA observed staff remove alcohol from kitchen and lock it away.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
80069(a)(1)
80069(2): Client Medical Assessment:
(a) Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan.(1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 80069(a)(1). LPA observed Resident #4 (R4) does not have medical assessment or TB test on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
1
2
3
4
Licensee agreed to submit a copy of R4's medical assessment and TB by POC date.
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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/21/2022 08:03 AM - It Cannot Be Edited


Created By: Treana White On 06/06/2022 at 01:11 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME - TRETHEWAY
FACILITY NUMBER: 397202947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(b)(1)
80068.2.(b)(1) - Needs and Services Plan:

(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1)The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 80068.2(b)(1). LPA observed 2 of 4 clients do not have updated IPP on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
1
2
3
4
Licensee agreed to obtain and send copy of 2 clients IPP to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4