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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557004883
Report Date: 09/03/2024
Date Signed: 09/03/2024 02:33:07 PM

Document Has Been Signed on 09/03/2024 02:33 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:WATCHFACILITY NUMBER:
557004883
ADMINISTRATOR/
DIRECTOR:		CLINT BOWERFACILITY TYPE:
775
ADDRESS:12801 CABEZUT ROADTELEPHONE:
(209) 533-0510
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 140CENSUS: 104DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Micah SuttonTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 9/3/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met Program Director Micah Sutton and explained the purpose of today's visit. It was learned that the Executive Director/Administrator separated from the company with the final day on site being July 26, 2024. There is no formal replacement designated at this time.

LPA Jensen toured the grounds and observed the paths to be free of obstruction. There is a shaded outdoor area and outdoor furniture for client use. There are no bodies of water on the property. Outdoor activity areas are adequately distanced from traffic to ensure client safety. LPA Jensen toured the interior of the facility including common areas, bathrooms, break rooms, kitchen, instructional rooms and offices. All rooms were observed to contain adequate lighting and furniture. All toxins were locked and inaccessible to residents in care. The water temperature in shared bathrooms was within the required range. The thermostat was set at 72 degrees for the comfort of the clients. There was no expired food observed. The facility maintains numerous first aid kits that are complete and in compliance. The facility has an automated external defibrillator (AED). Staff are appropriately certified in AED use. The fire extinguisher and carbon monoxide detectors were tested and found to be in good working order. The emergency disaster plan was reviewed and found to be in compliance. All exits were clearly marked. LPA Jensen engaged with numerous clients during the course of this visit. 3 clients were interviewed and 3 of 3 parties interviewed confirmed they are satisfied with all aspects of the program. LPA Jensen interviewed 3 staff members. All staff members interviewed were able to adequately answer questions related to meeting client needs and mandated reporting. LPA Jensen reviewed 2 staff files and 2 client files and found them to be complete and in compliance.

Technical Assistance is being provided on AED regulations and client oxygen use. A deficiency related to the facilities lack of an Administrator is being issued pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies can result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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Document Has Been Signed on 09/03/2024 02:33 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/03/2024 at 02:10 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: WATCH
FACILITY NUMBER: 557004883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(a)
Administrator -Qualifications and Duties
(a) All adult day programs shall have an administrator who meets either of the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an interview with the Program Director, the Executive Director/Administrator separated from the company with the last day on site being 7/26/24. No formal replacement has been appointed by the Licensee to date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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The Licensee shall designate a substitute that meets the qualifications of Section 82065, who shall be capable of and responsible and accountable for management and administration of the day program in compliance with applicable laws and regulations. The Licensee shall also notify the Department when a permanent replacement has been appointed.
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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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