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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390313065
Report Date: 08/27/2022
Date Signed: 08/27/2022 02:16:36 PM

Document Has Been Signed on 08/27/2022 02:16 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:CARCIDO'S GUEST HOME #4FACILITY NUMBER:
390313065
ADMINISTRATOR:CARCIDO, MEDINA T.FACILITY TYPE:
735
ADDRESS:2857 CHAUNCY CIRCLETELEPHONE:
(209) 477-4235
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
08/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Medinca Carcido, Licensee TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt made an unannounced visit on this day at approximately 01:00 p.m. for the purpose of conducting an abbreviated annual inspection. An annual inspection was previously conducted on April 25, 2022. LPA Hurt met with Licensee Medina Carcido, observed the following


• Covid precautions being followed
• Interior and exterior of the plant
• (7) seven day non-perishable and (2) day perishable supply of food
• Medications were observed to be locked up
• Fire extinguisher fully charged.
• Smoke detectors all operational.
• Hot water temperature measured 109 degrees.
• All employees requiring background checks are cleared.

There are no Health and Safety concerns at this time. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Licensee Medina Carcido.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2022
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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