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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202947
Report Date: 06/06/2023
Date Signed: 09/01/2023 09:27:34 AM

Document Has Been Signed on 09/01/2023 09:27 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 AC/SC, 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: 5DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Robert Felix, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date 06/06/2023. LPA met and toured with Administrator, Robert Felix. The administrator currently holds a certificate (#6015441735) that expires on 04/10/2024.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. The hot water temperature is maintained at 105 degrees Fahrenheit. All outdoor and indoor passageways were kept free from obstruction. Rooms were furnished appropriately. There was an adequate supply of toiletries, hygiene supplies, and extra linens. LPA observed clients’ linens were in good repair. There is a minimum of 7-day nonperishables and 2-day perishables foods.

The last disaster/fire drill was last conducted on 05/23/2023. Fire extinguishers, smoke detectors and carbon monoxide were checked. LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the clients needs.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/09/2023:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan
Liability Insurance

All staff have criminal record clearance and are associated to the facility. LPA reviewed clients’ file.
Exit interview conducted with Robert Felix and a copy of this report was provided.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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 09/01/2023 09:27 AM - It Cannot Be Edited


Created By: Renee Campbell On 06/06/2023 at 01:18 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: 06/06/2023

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
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Based on record review, the licensee did not comply with the section cited above in 3 of 5 client files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Adminiistrator will provide up to date IPP for residents to LPA via email by POC date to renee.campbell@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Emerita Curiel
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
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