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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203042
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:27:17 PM

Document Has Been Signed on 02/14/2022 03:27 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:DOUGHERTY'S GUEST HOME #2FACILITY NUMBER:
397203042
ADMINISTRATOR:DOUGHERTY, MIKE & THELMAFACILITY TYPE:
735
ADDRESS:331 STONEHAVEN WAYTELEPHONE:
(209) 957-6838
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Thelma DoughertyTIME COMPLETED:
03:35 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 2/14/21 at 12:34pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the lead caregiver and explained the purpose of the visit. Administrator Thelma Dougherty arrived at 1:15pm.

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 facility with a current census of 6. Facility has 4 bedrooms, 2 bathrooms. There is a formal dining room and covered patio leading out to the backyard. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 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. 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.

Water temperature reads 131.3*F in the bathroom and room temperature reads 69*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 11/1/2021. Facility has an emergency food and water kit. No obstructions to fire exits noted. All sharps and toxins are secured. LPA reviewed 5 staff charts. All first aid and COVID-19 vaccination cards are current.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held with Thelma Dougherty and a copy of this report was given to Thelma. Appeal rights provided
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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 2
Document Has Been Signed on 02/14/2022 03:27 PM - It Cannot Be Edited


Created By: Michael Bilger On 02/14/2022 at 03:12 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: DOUGHERTY'S GUEST HOME #2
FACILITY NUMBER: 397203042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA measured water temperature in bathroom used by clients with a reading of 131.3*F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2022
Plan of Correction
1
2
3
4
LIcensee will repair sink in clients bathroom to regulate temperature between 105*F-120*F

Licensee will maintain daily temperature log for 30 days to ensure appropriate regulatory water temperature of 105*F to 120*F
Licensee to conduct POC visit prior to clearing deficiency
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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2