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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 05/31/2022
Date Signed: 06/28/2022 10:47:08 AM


Document Has Been Signed on 06/28/2022 10:47 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: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:
05/31/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Rosemary Sababo and Letchia AgudaTIME COMPLETED:
03:00 PM
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LPA Johnson arrived unannounced to clear the POC's from visit dated 01/04/2022. The following deficiencies, initially cited during a visit on 01/04/2022, have been cleared:


Section Cited: 87705(c)(5)Date Due: 01/14/2022
Plan of Correction:
Licensee agrees to submit a plan of correction to LPA by 1/14/2022 on how R1 and R2's annual appraisal will be completed.		Corrections:
Cleared By Visit		Clearance Date:
05/31/2022
Section Cited: 87463(c)Date Due: 01/14/2022
Plan of Correction:
The facility shall obtain a current Needs and Services Plan for R1 thru R3. 		Corrections:
Cleared By Visit		Clearance Date:
05/31/2022
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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