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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317363
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:21:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/24/2024 12:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:UNITED CEREBRAL PALSY OF SAN JOAQUINFACILITY NUMBER:
390317363
ADMINISTRATOR/
DIRECTOR:		RAY CALLFACILITY TYPE:
775
ADDRESS:333 W. BENJAMIN HOLT DRIVETELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 70CENSUS: 33DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Lupe/ShirleyTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/24/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection.

LPA inspected the physical plant including but not limited to the kitchen, activity rooms, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 107.5 degrees Fahrenheit in Consumer bathroom sink, which is within the required range of 105 to 120 degrees. Fire/disaster drill was conducted on 10/2024.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 consumer/resident and 3 staff files, including criminal record clearances. LPA observed carbon monoxide detectors in the facility. Residents file review observed 1 of 5 ISP's with an outdated training for the communication devise for R1. (Advisory given)

Per the Title 22, Division 6 of California Code of Regulations. No deficiencies were cited during today's inspection.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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