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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 02/28/2022
Date Signed: 02/28/2022 02:57:39 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/28/2022 02:57 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:PLYMOUTH SQUAREFACILITY NUMBER:
390300536
ADMINISTRATOR:TYAH PETERSONFACILITY TYPE:
740
ADDRESS:1319 N MADISON STREETTELEPHONE:
(209) 466-4341
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:32CENSUS: 8DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Tyah PetersonTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Tyah Peterson and Juanita Jones.

LPA inspected physical plant including but not limited, bedrooms, bathrooms, and dining room area. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 120 degrees Fahrenheit in resident's bathroom sink (room 314), which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present.

LPA observed centrally stored medications locked inside the medication cart. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed an incident for R1, R1 had a fall and was alleged to have been ordered Home Health, however there is no record of an order by the Physician the fall was not reported. The facility started Home health services on 11/30/2020 and continued through 1/21/21, there is no discharge summary. LPA reviewed 8 resident files and 4 staff files. During the Staff file review LPA observed S1 had an missing health screening. LPA also observed an incident for a fall for R2 on 8/17/2021, the fall was not reported to the department.

First aid kit was checked and is complete. Fire drill was completed on 1/20/2022.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, deficiencies were observed and cited during this visit. Exit interview held and a report given at the conclusion of the visit.

Continued
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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 02/28/2022 02:57 PM - It Cannot Be Edited

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: PLYMOUTH SQUARE
FACILITY NUMBER: 390300536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2022
Section Cited

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General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment.
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LPA observed staff did not have a health screening and TB test results in S1
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Type B
03/11/2022
Section Cited

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D)Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission;
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date and nature of event; This regulation was not met as evidence by: The licensee did not ensure that the facility provided a written report to licensing for the fall of R1 or R2. This poses a potential risk to residents in care.
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Statement shall include the requirements as outlined in the regulation identified in this citation.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
LIC809 (FAS) - (06/04)
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