<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393611645
Report Date: 05/31/2019
Date Signed: 05/31/2019 01:15:32 PM

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 250
SACRAMENTO, CA 95833
FACILITY NAME:CAMP HUTCHINS OF LODI MEMORIAL HOSPITALFACILITY NUMBER:
393611645
ADMINISTRATOR:ZAMORA, MARIAFACILITY TYPE:
850
ADDRESS:125 S. HUTCHINS STREETTELEPHONE:
(209) 334-2267
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:53CENSUS: 28DATE:
05/31/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria ZamoraTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Ponce met with Director Maria Zamora for a Case Management- incident Inspection regarding an unusual Incident that took place on May 15th, 2019. During the inspection, LPA conducted interviews, collected pertinent documentation and made observations. During the inspection, LPA Ponce also discussed water testing for lead, along with Pesticide Training that can be taken online.

no Title 22 Regulations were cited. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
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 1