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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700061
Report Date: 03/12/2024
Date Signed: 03/12/2024 10:58:10 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/12/2024 10:58 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:
03/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jane MoforTIME COMPLETED:
11:15 AM
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On 3-12-2024 at 10:10am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct a annual inspection visit. Today's visit is due to a previously attempted visit conducted on 11-29-23. LPA met with the administrator Jane Mofor and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an adult residential facility with a current census of 0. Facility has 4 bedrooms and 2 bathrooms for resident use. 1 extra bedroom is for staff use. Facility has a dining area off the kitchen and a formal living room. LPA observed that there are currently no residents living at the facility and no staff employed as a result.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 68*F. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Medication storage area was observed to contain a locking mechanism.

Facility does not contain any bodies of water. LPA observed personal rights posted. LPA reviewed facility’s disaster plan to ensure regulatory compliance. No obstructions to fire exits noted.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Jane Mofor
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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