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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003251
Report Date: 01/18/2022
Date Signed: 01/21/2022 07:13:43 AM

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:ASTORIA GARDENSFACILITY NUMBER:
397003251
ADMINISTRATOR:ADALINE KIEHNFACILITY TYPE:
740
ADDRESS:1960 WEST LOWELLTELEPHONE:
(209) 833-2200
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:77CENSUS: 43DATE:
01/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:A. KiehnTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit conducted on 1/13/2022.

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited on 1/13/2022 has not been cleared. The temperature in Room 23 was measured at 126 not within the required range of 105 to 120 degrees. .

Deficiency cited under Title 22 Regulations has not been cleared. Licensee did not complied with the terms of the POC by POC due date.

Facility was recited for the violation and civil penalties were assessed.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ASTORIA GARDENS
FACILITY NUMBER: 397003251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2022
Section Cited

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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LPA measured / tested hot water at 126 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a health and safety risk to resident in care.
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Test hot water in the bathroom to meet Title 22 regulations. Send 3 days hot water temperature to LPA.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2