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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390305586
Report Date: 01/24/2021
Date Signed: 01/26/2021 09:47:39 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:TENDER LOVING CARE GUEST HOMEFACILITY NUMBER:
390305586
ADMINISTRATOR:ESTHER JOHNSONFACILITY TYPE:
740
ADDRESS:2829-2831 PIXIE DR.TELEPHONE:
(209) 943-7558
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY:14CENSUS: 8DATE:
01/24/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kashan Bell (Licensee)TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check on this day. LPA met with Kashan.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. During the inspection LPA observed signage and PPE equipment throughout the facility. The resident were in their rooms and were observed wearing mask when exiting their rooms to go to the bathroom. All residents in care appeared safe and comfortable.

Licensee confirmed that the staff in question about being positive was Gernaine Brown and the facility will provided information for Gernaine Brown who tested positive dates to be determined. Licensee will forward the reporting information to the department on 1/25/2021. Licensee confirmed that Gernaine has not worked at the facility for sometime.


Exit interview conducted with Kashan.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2021
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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