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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390305586
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:30:30 PM


Document Has Been Signed on 04/13/2022 03:30 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: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: 0DATE:
04/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Kashan BellTIME COMPLETED:
04:05 PM
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On 4-13-22 at 3:08pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to conduct an inspection proceeding the closure of the facility. LPA met with Administrator Kashan Bell and explained the purpose of the visit. A Notice of Facility Closure was received by the Regional Office with a facility closure date of 4/1/2022.

LPA toured the facility with the administrator. LPA observed that there were no residents at the facility. Administrator stated during visit that all residents have moved out as of 3-15-22.

LPA collected the original License from Administrator during today's visit. Administrator was advised that the facility will be closed in the system as of 4-14-22. An exit interview was conducted with Kashan Bell and a copy of this report was left Kashan.

Link to survey for Facility Closure provided to Kashan Bell.

www.surveymonkey.com/r/facilityclosure
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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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