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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 08/03/2021
Date Signed: 08/04/2021 10:10:56 AM

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:WILLY DE MESAFACILITY TYPE:
740
ADDRESS:1319 N MADISON STREETTELEPHONE:
(209) 466-4341
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:32CENSUS: 13DATE:
08/03/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tyah PetersenTIME COMPLETED:
02:30 PM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit conducted on 07/02/2021 .


Citation 87405(a) Administrator- Qualifications and Duties: (All Facilities shall have a qualified and currently certified administrator). The facility has identified Breana Larkin as the acting Administrator, her information is on the pending list as of 7/13/2021 . The facility has not provided the required documentation and will continue to be assessed civil penalties for failure to correct this citation.


Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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