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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:25:47 PM

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:
08/27/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Tyah PetersenTIME COMPLETED:
01:30 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 provided the required documentation on this date. The information provided has a signed date of 8/13/2021. Civil penalties for failure to correct this citation will be concluded as of the date of the signed documents (8/13/2021).

The facility will provide the department with the listed information by 8/30/2021.
1. Administrator will be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. Licensee agreed that Administrator will be on site 20 hours/wk. during business hour 9-5 PM Send LIC 500 to CCL by 8/30/2021.

2. Licensee will designate substitute when the administrator is absent from the facility who meets the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and administration of the facility in compliance with regulation. Send LIC 308 to CCL by 8/30/2021.

Please be advised that an informal office meeting has been scheduled for Friday, September 10th, 2021 at 10:30am to discuss the annual inspection completed on 7/22/2021. The meeting will be held via Zoom. Exit interview conducted.

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

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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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