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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:01:06 PM


Document Has Been Signed on 08/30/2023 03:01 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:
08/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Rosemary Sababo and Letchia AgudaTIME COMPLETED:
03:03 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a case management visit. LPA met with Staff explained the purpose of the visit.

R1 was given a 30 day notice for failing to follow house rules and not taking medication. R1's primary care physician was notified. R1 also is being treated by mental health and is currently at St. Joseph's hospital for medication management.

The facility also reported that R1 broke the television and the police had to come out and assist in redirecting R1. R1 would not calm down and was taken by the police to behavioral health and then transferred to St. Joseph's hospital.

R1 will not be coming back to the facility, R1 needs a higher level of care.

No deficiencies were cited as a result of this visit.

An exit interview was conducted.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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