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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 02/06/2024
Date Signed: 02/06/2024 12:41:59 PM


Document Has Been Signed on 02/06/2024 12:41 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: 6DATE:
02/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:LOLITA MATA - DIRECT CARE STAFFTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced case management visit deficiency visit. LPA met with direct care staff and explained purpose of visit.

LPA cleared plan of correction (POC) on 1/9/2024 for fire and earthquake drills not being conducted every three months. The facility conducted fire/disaster drills with residents on 7/8/2023, there not in compliance. It was a repeated violation within twelve months, so facility received a civil penalty on 1/8/2024.

LPA used the wrong regulation out of adult residential instead of senior regulations. Today's visit clears the POC and no further action is required by licensee.

Exit interview held with direct care staff. A copy of report was left at facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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