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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 12/15/2023
Date Signed: 12/15/2023 11:52:11 AM


Document Has Been Signed on 12/15/2023 11:52 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/15/2023 11:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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On 12/15/23 at 9:35am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a health and safety visit at a lodging located at 33 N Center St, Stockton, CA 95202. LPA met with facility staff Maria Nelina Estrada and explained the purpose of the visit. Residents in care have been temporarily relocated to this lodging due to facility location undergoing pest control services. Present during this visit are 9 residents in care with 3 staff on duty.

At 9:45am, LPA and staff, Maria, visited and observed each resident's rooms. Five rooms continues to be occupied by residents with 2 rooms occupied by staff. Observed are 2 residents to each room, except for 1 resident who has a private room. LPA observed rooms to be clean and sanitary with no foul odors, and contain full size refrigerators, televisions, full size beds, night stands, and adequate storage space. Laundry continues to be provided by facility staff using the lodging laundry services. Interview of residents in care informed LPA that residents are doing fine. Per interview and document review, staff are checking on residents every 30 minutes.

LPA observed residents' medications are kept locked one of the staff room and inaccessible to residents in care. LPA observed all resident files on site and also kept in one of the staff room. Observed are adequate amount of food and are being stored in one of the staff room. Additionally, food is ordered outside by facility staff for residents. Per interview with the staff, staff continue to follow the developed menu for residents which includes breakfast, lunch, dinner and 3 snack times. Food options include fruit, cereal, pastries, bread, sandwich meat, cheese, and fish. Beverages include milk, water, and juice products. Food ordered from outside is also included on the menu.

Licensing department will continue to conduct health and safety checks. Tentative date to return to facility is 12/18/23 pending clearance by pest control. No citations issued today. An exit interview was conducted with Maria Nelina Estrada and a copy of this report was provided.

Note: This report was amended on 12/15/23 due to the incorrect date inputted at the first paragraph.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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