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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622570
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:09:35 PM


Document Has Been Signed on 07/20/2023 12:09 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MARTIN, LAKISHAFACILITY NUMBER:
393622570
ADMINISTRATOR:MARTIN, LAKISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 271-4228
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:14CENSUS: 2DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Licensee: Lakisha MartinTIME COMPLETED:
12:30 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
On July 20th, 2023, Licensing Program Analysts (LPA’s) Mariya Melnichuk and Lauren Scott conducted a case management inspection at the facility. Licensee stated that she temporarily relocated between end of February and end of May. She stated that she provided afternoon care for children.

Title 22 deficiency has been cited on subsequent page, LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, acknowledging receipt of Licensing Reports LIC 809D in each child's files.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Facility Representative, Lakisha Martin. A copy of this report and appeal rights were discussed and left the Facility Representative. A Notice of Site Visit was posted by LPA’s Melnichuk and Scott and must remain posted for 30 days.Failure to comply with posting requirements shall result in an immediate civil penalty of $100

SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Mariya MelnichukTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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


Document Has Been Signed on 07/20/2023 12:09 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MARTIN, LAKISHA
FACILITY NUMBER: 393622570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2023
Section Cited
CCR
102417(a)

1
2
3
4
5
6
7
(a)The licensee shall be present in the home... Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
This requirement was not met as evidenced by
1
2
3
4
5
6
7
Licensee will be present in the facility for at least 80% of working hours. LPA will verify via visit/ inspection.
8
9
10
11
12
13
14
Licensee temporarily relocated from her home for a period of time and was only providing care for children in the afternoons.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Mariya MelnichukTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2