390300536-6-15-2023-27-AS-KHOS-CT7NL6-20230627103302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 390300536
Report Date: 06/15/2023
Date Signed: 06/15/2023 07:46:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230607171715

FACILITY NAME:	PLYMOUTH SQUARE		FACILITY NUMBER:	390300536
ADMINISTRATOR:	TYAH PETERSON		FACILITY TYPE:	740
ADDRESS:	1319 N MADISON STREET		TELEPHONE:	(209) 466-4341
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95202
CAPACITY:	32	CENSUS: 4	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	05:38 PM
MET WITH:	Diane Rohl HR Director		TIME COMPLETED:	06:54 PM

ALLEGATION(S):

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Facility is without a designated administrator.

INVESTIGATION FINDINGS:

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This allegation is substantiated based on the case management visit that was completed on 6/5/2023. The facility received a citation with a plan of correction on 6/5/23. The plan of correction has not been completed and the facility has not made plans know regarding the placement of an certified Administrator.

During the visit LPA was made aware that both the Skilled and the Assisted sides of the facility are without an Administrator.

This will be cross reported to the Department of Public Health.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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