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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390311376
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:31:53 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:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
390311376
ADMINISTRATOR:RICK A. REEDFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE ROADTELEPHONE:
(209) 931-4206
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 12DATE:
12/01/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Leah AguinaldoTIME COMPLETED:
03:00 PM
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On 12/1/21 at 2:25pm Licensing Program Analyst (LPA) Kevin Gould arrived at Cherokee Retirement Home (ARF) for the purpose of conducting a POC inspection and ensure the floor in the kitchen has been repaired. LPA met with staff and together conducted a tour of the corrected areas of the home.

LPA observed the floor in the Kitchen is solid with no missing floor panels and no longer poses a potential health, safety or personal rights risk for residents in care. LPA has cleared the deficiency and a copy of the POC clearance letter will be generated and provided to the facility.

There are no deficiencies cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the licensee and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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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