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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 07/07/2023
Date Signed: 07/12/2023 12:17:18 PM


Document Has Been Signed on 07/12/2023 12:17 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:PLYMOUTH SQUAREFACILITY NUMBER:
390300536
ADMINISTRATOR:TYAH PETERSONFACILITY TYPE:
740
ADDRESS:1319 N MADISON STREETTELEPHONE:
(209) 466-4341
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:32CENSUS: DATE:
07/07/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Diane RohlTIME COMPLETED:
02:55 PM
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LPA Albert Johnson made an unannounced visit to the facility to verify correction of citations issued during the POC visit conducted on 06/15/2023 .

Citation 87405(a) Administrator- Qualifications and Duties:
(All Facilities shall have a qualified and currently certified administrator).

The facility has not identified an acting Administrator. The facility has not provided the required documentation and will continue to be assessed civil penalties for failure to correct this citation.

LPA was made aware that all residents have moved out.

The facility's intentions will be to close, please follow the guidelines for closure:
(H & S Code 1569.682).

Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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