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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700266
Report Date: 05/26/2022
Date Signed: 05/31/2022 03:35:57 PM

Document Has Been Signed on 05/31/2022 03:35 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:CABRERA'S GUEST HOMEFACILITY NUMBER:
342700266
ADMINISTRATOR:CABRERA, DIGNAFACILITY TYPE:
735
ADDRESS:1229 SOUTH HARRISON STTELEPHONE:
(209) 598-7588
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Ederlinda NovalTIME COMPLETED:
11:54 AM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a case management visit. LPA met with Ederlinda Noval (Staff) and explained the purpose of the visit.

The facility reported two positive cases of Covid. The facility requested N-95 mask, LPA provided the mask and technical support to the facility. The residents are isolating in there rooms and are Asymptomatic.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.


Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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