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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202964
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:10:50 PM

Document Has Been Signed on 12/07/2022 02:10 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ST. PAUL'S HOMEFACILITY NUMBER:
397202964
ADMINISTRATOR:GAZUZ, MINERVINAFACILITY TYPE:
735
ADDRESS:1212 HUTCHINSON AVENUETELEPHONE:
(209) 477-2475
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
12/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Minervina GazuzTIME COMPLETED:
12:49 PM
NARRATIVE
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On 12-7-22 at 10:33am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA was greeted by Administrator Minervina Gazuz and LPA explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed adult residential facility with a current census of 5. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 6 bedrooms and 2 bathrooms. There is a formal living room and family/TV room for residents. All knives, toxins, and other chemicals were inaccessible to residents in care.

The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors as required. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed staff cleaning schedule with various cleaning items checked off for month of October and November. Additionally, LPA observed food checkoff list including monitoring for expired food items. Resident rooms did not contain spider webs or other evidence of insect infestation. Light bulbs and ceiling fans were operational in all resident rooms during today's visit. Facility has received technical support program (TSP) service from department. LPA observed paperwork from TSP in place with evidence of follow up noted.

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ST. PAUL'S HOME
FACILITY NUMBER: 397202964
VISIT DATE: 12/07/2022
NARRATIVE
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Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 72*F. LPA observed the facility to have adequate food supply during today’s visit. Resident rooms were sanitary and had the required furniture and furnishings. Smoke and carbon detectors were in adequate repair. Facility has an emergency food and water kit. Fire extinguisher is fully charged and dated 7/10/22. Licensee is current on training requirements including incident reporting, general reporting requirements, and personal rights. LPA reviewed medication log sheets and medication storage area for residents. Facility currently has vitamins and supplements available to residents in care without a prescription in place to assist residents with medication.

Per California Code of Regulations, Title 22, deficiencies were cited during this visit and noted on LIC 809D. Exit interview was held and a report was given to Administrator Minervina Gazuz. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2022 02:10 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/07/2022 at 01:34 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: ST. PAUL'S HOME
FACILITY NUMBER: 397202964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
80075(b)

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Health Related Services. (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee will ensure order are in place for all residents in care for as needed vitamins and supplements. Licensee to submit copies of new physician orders to LPA by POC due date.

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Based on interview, record review, and observation, licensee did not ensure residents in care were assisted properly with medications in that vitamins and supplements were given to residents in care as needed without a physician's order. This poses a potential health and safety risk to residents in care.
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Licensee will conduct a medication audit to ensure all physician orders for medications are current. Complete audit to be submitted to LPA by POC due date.

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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: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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