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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701194
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:45:36 PM

Document Has Been Signed on 03/21/2025 03:45 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HOSPITALITY HOUSEFACILITY NUMBER:
502701194
ADMINISTRATOR/
DIRECTOR:		PADILLA, LORRAINEFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 80CENSUS: 49DATE:
03/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Lorraine Padilla TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Case Management visit. LPA Lund met with Administrator Lorraine Padilla and explained the reason for the visit. Census 49

LPA Lund received an Unusual/Incident Injury Report from the facility on 3/19/2025 regarding incident on camera from 3/14/2025. Administrator Lorraine Padilla reviewed footage of Staff (S1) aggressively pulling a Resident (R1) by sweater and proceeding to forcefully pulling R1 by the arm resulting R1 falling to the ground. Footage also shows that S1 aggressively pulled a walker from Resident (R2). When Administrator Lorraine Padilla reviewed the footage, she put S1 on administrative leave pending an investigation. Administrator Lorraine Padilla notified responsible party for R1 who came the next day to discuss the incident along with R1's Primary Care Doctor (PCD) who had a Nurse Practitioner (NP) come to the facility to examine R1, who had no signs of trauma or injury. Stanislaus County Sheriff Department Case #S25010120.

Deficiencies were cited during today's visit. Exit interview held and copy of the report and a copy of the appeal rights left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 03/21/2025 03:45 PM - It Cannot Be Edited


Created By: Jason Lund On 03/21/2025 at 03:22 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: HOSPITALITY HOUSE
FACILITY NUMBER: 502701194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2025
Section Cited
CCR
87468.2(a)(1)

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"residents in privately operated residential care facilities for the elderly shall have all of the following personal rights ... To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications,.....
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Administrator Lorraine Padilla will all staff going over Personal Rights and email LPA Lund a copy of meeting.
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This requirement is not met as evidenced by: Staff (S1) footage of Staff (S1) aggressively pulling a Resident (R1) by sweater and proceeding to forcefully pulling R1 by the arm resulting R1 falling to the ground.
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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:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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