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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:38:39 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: 12DATE:
09/15/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:West Coast Regional Manager, Briana Larkin, Administrator, Tyah Peterson,TIME COMPLETED:
02:30 PM
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An Informal Conference was conducted today at the Sacramento Regional Office via Zoom. Present for the meeting was West Coast Regional Manager, Briana Larkin, Administrator, Tyah Peterson, Licensing Program Manager Stephenie Doub, Licensing Program Analyst Albert Johnson .

The purpose of the informal conference was to address the facility’s substantial compliance concerns. The Department has concerns stemming from site inspections on dates: 7/2/2021

The licensee was told that this Informal Conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could then lead to referral to the Department's legal division for possible revocation of license. Issues discussed during the meeting were:

87405(a) Administrator- Qualifications and Duties

In an effort to support the facility maintaining substantial compliance with health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns. Plan to address compliance concerns:

• The Department has received an up to date LIC 200, LIC 500 and LIC 308 and a letter from the board.

The facility will have a current employee become an Administrator or use B. Larkin's Administrator Certificate in the event of an absent Administrator in the future.

No citations issued at this time. Exit interview conducted and copy of report provided to facility representative
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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