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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 10/21/2022
Date Signed: 02/23/2023 02:30:06 PM


Document Has Been Signed on 02/23/2023 02:30 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: 7DATE:
10/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tyah PetersonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Johnson arrived at facility to conduct a Case Management visit due to an Incident Report submitted to CCL for a unwitnessed fall.

During the file review LPA was informed that R1 had another visit to the emergency room on 10/20/2022 for trouble breathing. (R1) was admitted to the hospital and will return to facility when stabilized.

Administrator will have R1 re-evaluated prior to being re-admitted to the facility in order to update Needs and Services Plan and to ensure resident's safety.

LPA reviewed resident file, current Needs and Services Plan. Administrator will submit (R1's) updated LIC 602 if any changes were made and Needs and Services Plan to CCL when R1 returns.

No deficiencies cited.

Exit interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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