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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700061
Report Date: 11/29/2023
Date Signed: 11/29/2023 11:31:46 AM

Document Has Been Signed on 11/29/2023 11:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAINT PETERS RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
392700061
ADMINISTRATOR:MOFOR, JANEFACILITY TYPE:
735
ADDRESS:2108 CANBY OAK DRTELEPHONE:
(510) 472-3989
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 6CENSUS: 0DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jane MoforTIME COMPLETED:
11:40 AM
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On 11-29-23 at 10:40am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct an annual inspection visit. LPA rang door bell with no answer after 5 minutes. LPA observed blinds were closed and lights off at the facility. LPA called and spoke with Administrator Jane Mofor who stated facility is still waiting for regional center vendorship and neither staff or residents are in the facility as a result. Administrator was not available to arrive at facility due to a long distance work schedule today.

Annual inspection was unable to be completed today and will be rescheduled for a later date.

An exit interview was conducted with Administrator via phone and a copy of this report was emailed to Administrator with request for return with signature.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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