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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:32:11 PM


Document Has Been Signed on 07/12/2023 04:32 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:ARLYN'S GUEST HOMEFACILITY NUMBER:
392700049
ADMINISTRATOR:DE LA CRUZ, ARLYN MFACILITY TYPE:
740
ADDRESS:1633 S STOCKTON STREETTELEPHONE:
(209) 392-7049
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
07/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rosemary Sababo and Letchia AgudaTIME COMPLETED:
02:55 PM
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LPA Johnson arrived unannounced to clear the POC's from visits dated 06/20/2023 and 6/23/23. The following deficiencies, initially cited during those visits have been cleared:

Section Cited: 87468.1(a)(3)Date Due: 06/22/2023
Plan of Correction:
The lock was removed during the visit. The licensee will provide a statement to the LPA Albert.Johnson@dss.ca.gov that this regulation has been read, understood by themself and the staff.		Corrections:
Cleared By Visit		Clearance Date:
07/12/2023
Section Cited: 87411(g)(2)Date Due: 06/22/2023
Plan of Correction:
The licensee will submit to CCL Albert.Johnson@dss.ca.gov a transfer request on 06/22/23.
Corrections:
Cleared By Visit		Clearance Date:
07/12/2023
Section Cited: 87309(a)Date Due: 06/22/2023
Plan of Correction:
The licensee will provide proof of locks repaired or relpaced on areas that store medications and chemicals to Albert.Johnson@dss.ca.gov. 		Corrections:
Cleared By Visit		Clearance Date:
07/12/2023
Section Cited: 87705(C)(4)(a)Date Due: 06/22/2023
Plan of Correction:
The licessee will submit a Plan of correction by 06/22/23 to Albert.Johnson@dss.ca.gov.		Corrections:
Cleared By Visit		Clearance Date:
07/12/2023
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049
VISIT DATE: 07/12/2023
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Section Cited: 87202Date Due: 06/24/2023
Plan of Correction:
Administrator shall replace battery in smoke detector by POC date and submit a statement of compliance via email to CCL.		Corrections:
Cleared By Visit		Clearance Date:
07/12/2023
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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