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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 01/18/2025
Date Signed: 01/18/2025 04:27:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/18/2025 04:27 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:ARLYN'S GUEST HOMEFACILITY NUMBER:
392700049
ADMINISTRATOR/
DIRECTOR:
DE LA CRUZ, ARLYN MFACILITY TYPE:
740
ADDRESS:1633 S STOCKTON STREETTELEPHONE:
(209) 392-7049
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:12 PM
MET WITH:Arlyn De La Cruz TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 1/18/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Arlyn De La Cruz and explained the purpose of the visit.
The purpose of this visit was to conduct an annual visit.

It was learned that this facility is undergoing changes to obtaining Regional Center Services to expect and retain Level 4I elderly residents. This facility currently has no residents in care.
This facility was formerly an RCFE that served and retained 6 elderly residents. The facility residents were served proper notices and were relocated to different licensed facility.
Current census was 0. A brief interview with FDA De La Cruz.

FDA De La Cruz has current administrator certificate
The administrator has a current administrator certificate #7001834740 and expires on 11/23/2025.
A tour of the facility was conducted.
Smoke detectors and carbon monoxide detectors were observed to be in good compliance at this time. Fire extinguisher was serviced by a local fire company 12/13/2024.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.
Medication cabinet, located in the kitchen area, was toured. First aid kit was observed to be present and contained all required components at this time.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907
DATE: 01/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049
VISIT DATE: 01/18/2025
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A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. A tour of the resident bathrooms was conducted. Tour of 2 staff bedrooms were also conducted.
Hot water temperatures were taken and measured within the allowed range of 105-120 degrees. Linen closet was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. A tour of the exterior grounds was conducted.
A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time with no hazards present.
Garage area was toured. A washer and dryer was identified. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610e
-Updated Fire Clearance and facility sketch
-A copy of the facilities new program design.

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2025
LIC809 (FAS) - (06/04)
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