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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332206
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:18:18 PM

Document Has Been Signed on 02/23/2023 01:18 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:DEL RIO GUEST HOMEFACILITY NUMBER:
500332206
ADMINISTRATOR:SILER, DOROTHYFACILITY TYPE:
735
ADDRESS:2841 PATTERSON RDTELEPHONE:
(209) 869-2420
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 15CENSUS: 11DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Saudia WitakerTIME COMPLETED:
01:20 PM
NARRATIVE
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On 2/23/23 at approximately 10:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Administrator Saudia Whitaker and explained the purpose of today's visit. Saudia holds current Administrator's certificate # 6020044735 good through 8/30/2024.

LPA Jensen toured the facility including grounds, laundry room, activity room, kitchen, bedrooms and bathrooms. The grounds were observed to be clear of debris and all pathways were unobstructed. There are no bodies of water on the property. All window screens were observed to be in good repair. LPA Jensen observed adequate outdoor furniture and shaded areas for resident activities.

The thermostat was set at 21 degrees Celsius (70 degrees F) which falls within the required regulatory range of 68-85 degrees F. LPA Jensen observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. All knives and medications were observed to be locked and inaccessible to residents in care. LPA Jensen tested the carbon monoxide detector and found each to be in good repair. The fire extinguishers were last serviced in January of 2023 and are in compliance. The first aid kit was observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual. The bathrooms were observed to have non-slip flooring in the shower areas. LPA Jensen observed 7 disposable razors in an unlocked bathroom drawer in the bathroom located in the bedroom hallway. LPA Jensen observed paint in cans in the bathroom storage cabinet in the bathroom adjacent to the laundry room.

All staff were observed to be finger print cleared and associated to the facility. Resident Rights and COVID Infection signs were posted in prominent areas in the facility. A Residents council meeting was last held in January of 2023.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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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: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206
VISIT DATE: 02/23/2023
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Continued form LIC 809C...

LPA Jensen requested and received a current copy of the liability insurance, surety bond and LIC 500. The infection control inspection tool was used during this site visit.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2023 01:18 PM - It Cannot Be Edited


Created By: Maja Jensen On 02/23/2023 at 12:53 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: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of razors and paint accessible to clients in care, the licensee did not comply with the section cited above in 2 of 2 bathrooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Effective immediately, Licensee agrees to lock razors and have staff unlock and relock razors after each use. In addition, Licensee agrees to do a walk through after every contractor visit. Licensee will send a signed attestion to maja.jensen@dss.ca.gov within 24 hours
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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


LIC809 (FAS) - (06/04)
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