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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332206
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:18:17 PM

Document Has Been Signed on 08/03/2022 12:18 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: 8DATE:
08/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Pamela HightowerTIME COMPLETED:
12:30 PM
NARRATIVE
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On 8/3/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit. LPA Jensen met with Direct Support Provider Pamela Hightower and explained the purpose of today's visit. Pamela Hightower also called Licensee Saudia Whitaker and explained the purpose of today's visit.

While at the facility LPA Jensen observed the staff bathroom located adjacent to the office and laundry room to be in disrepair. The baseboard next to the shower door was observed to have separated from the wall and was exposing a significant level of dry rot. LPA Jensen interviewed Licensee Whitaker who confirmed the facility was planning to remodel the staff bathroom.

Deficiencies for non-compliance are being cited today under the California Code of Regulations (CCR's), Title 22, Division 6.

An exit interview was conducted and a copy of this report along with appeal rights were left with Pamela Hightower.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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Document Has Been Signed on 08/03/2022 12:18 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/03/2022 at 12:03 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
, 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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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The Licensee agrees to repair the baseboards and dry rot in the staff bathroom adjacent to the office by the POC due date and submit a photograph of repairs via email to maja.jensen@dss.ca.gov
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Based on LPA's observation of the staff bathroom baseboards next to the shower door separating from the wall and exposing dry rot. This poses a potential health, safety and personal risk to residents in care.
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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: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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