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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390318201
Report Date: 12/15/2021
Date Signed: 12/15/2021 10:22:23 AM

Document Has Been Signed on 12/15/2021 10:22 AM - 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:GIER CARE HOMEFACILITY NUMBER:
390318201
ADMINISTRATOR:GIER, DOMINGAFACILITY TYPE:
735
ADDRESS:9009 CORNWALL DRIVETELEPHONE:
(209) 952-8545
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 4DATE:
12/15/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Dato, Facility ManagerTIME COMPLETED:
10:30 AM
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 LPA Bruce Jacobs arrived at this facility unannounced to conduct a Plan of Correction visit. LPA was met by Administrator Dominiga Geir and Facility Manager Maria Dato. LPA was screened upon entry for COVID precautions. LPA explained the purpose of the visit and was accompanied on facility tour

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with 4 clients at this time.

LPA observed areas of the physical plant that have been addressed. The bathroom ceiling has been cleaned and repainted and the deficiency is cleared.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given , POC will be cleared and letter stating the same to be provided to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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