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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203001
Report Date: 09/24/2024
Date Signed: 09/27/2024 11:32:31 AM

Document Has Been Signed on 09/27/2024 11:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WESTON RANCH CARE HOMEFACILITY NUMBER:
397203001
ADMINISTRATOR/
DIRECTOR:		ORPILLA, MARIA TERESAFACILITY TYPE:
735
ADDRESS:2280 PISA CIRCLETELEPHONE:
(209) 406-8666
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Virginia Baldanado, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 09/24/2024. LPA Campbell met with Virginia Baldanoda, Caregiver and explained the purpose of the visit.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) ambulatory mentally disordered residents between the ages of 18-59. LPA Campbell observed the facility to be free of odor, clean and in good repair. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. The hot water temperature was measured in the kitchen and bathroom. The resident bathroom water temperature measured at 112 degrees. Fahrenheit. The kitchen was temperature was measure at 107 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair and were tested during the facility visit. The fire extinguisher was last checked on 06/07/2024. The facility thermostat was observed at 81 degrees Fahrenheit. LPA Campbell checked medication storage and found medication to be locked away and inaccessible to clients. The first aid kit was complete and contained scissors, tweezers and a thermometer. The first aid manual was observed by LPA Campbell next to the first aid kit. LPA Campbell requested client files for review. LPA Campbell reviewed 5 resident files of 6 resident files. Resident files were complete. In regards to toxins and cleaning solutions, when residents needed to retrieve drying towels locked in the garage,, staff unlocked the door and walked away, leaving the door unlocked. During the visit, staff relocated the drying towels to a cord in the backyard until the administrator can add locks to the cabinets in the laundry room for the cleaning products.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WESTON RANCH CARE HOME
FACILITY NUMBER: 397203001
VISIT DATE: 09/24/2024
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The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 09/30/2024 by 5:00 PM by the end of day:

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, see 809-D for deficiency cited during this visit. The deficiency was corrected during the visit by hanging towels outside until the administrator could add locks to the laundry cabinets. Failure to correct the deficiency may result in additional civil penalties.

Exit interview held with caregiver. A copy of reports, civil penalty, appeal rights were left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2024 11:32 AM - It Cannot Be Edited


Created By: Renee Campbell On 09/24/2024 at 01:03 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WESTON RANCH CARE HOME
FACILITY NUMBER: 397203001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)


This requirement is not met as evidenced by: Upon entry, LPA Campbell observed poisons and cleaning supplies were not locked away and were available to clients
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when staff allowed locked storage for cleaning supplies to remain unlocked. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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During this visit, staff relocated a towel drying station to the backyard away from cleaning supplies until the administrator can add locks to the cabinets in the laundry room by POC date. LPA Campbell consulted with staff about keeping the laundry room locked as well.
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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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