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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202975
Report Date: 10/24/2023
Date Signed: 10/26/2023 10:27:31 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/26/2023 10:27 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:UNITED CEREBRAL PALSY, PROGRAM WITHOUT WALLSFACILITY NUMBER:
397202975
ADMINISTRATOR:JOANNE JOHNSONFACILITY TYPE:
775
ADDRESS:6709 PLYMOUTH ROAD, SUITE CTELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 45CENSUS: DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:S. Pech, S. Murillo and R. CopperriderTIME COMPLETED:
03:19 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit.

LPA and Staff inspected the physical plant including but not limited to the kitchen, Activities room, resident bathrooms, medication rooms, and outside front courtyard. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. Hot water temperature was measured at 110.5 degrees Fahrenheit in resident's bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers, smoke detectors and carbon monoxide detector were in compliance with fire safety. LPA observed (PRN) centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 6 resident and 3 staff files, including criminal record clearances. LPA observed during the file review for the residents 2 outdated Restricted Health Care Plans for (R1 and R2). First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed during this visit. Exit interview held with Staff and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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 10/26/2023 10:27 AM - It Cannot Be Edited


Created By: Albert Johnson On 10/24/2023 at 02:38 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: UNITED CEREBRAL PALSY, PROGRAM WITHOUT WALLS
FACILITY NUMBER: 397202975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
82092.2

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The licensee who chooses to care for a client with a restricted health condition may use a copy of the Restricted Health Care Plan from the client's residential setting provided that the information required in Section 82092.2(a)(4), specific to the day program, is added. If the client does not have a Restricted Health Condition Care Plan, the licensee must develop a plan. The plan must include all of the following: (1) Documentation that the client and the client's authorized representative, if any, the client's physician or a licensed professional designated by
the physician, and the placement agency, if any, participated in the development of the plan.(2) Documentation by the client's physician or a licensed professional designated by the physician, of the following: (A) Stability of the medical condition. (B) Medical conditions that require services or procedures. (C) Specific services needed. (D) Client's ability to perform the procedures. (E) The client does not require 24-hour nursing care and/or monitoring.
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Licensee/Administrator shall submit an updated health care plan for all residents with a restricted health conditon. This shall be done by POC date 11/07/2023.
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This requirement is not met as evidenced by observation, LPA observed expired restricted health care plans (RHCP) for 2 of 6 residents reviewed.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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