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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700061
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:37:46 AM

Document Has Been Signed on 02/06/2025 11:37 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/
DIRECTOR:
MOFOR, JANEFACILITY TYPE:
735
ADDRESS:2108 CANBY OAK DRTELEPHONE:
(510) 472-3989
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 6CENSUS: 0DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Jane MoforTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 2-6-2025 at 10:31am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility to conduct an annual inspection visit. 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 and bathroom is for staff use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. Facility is currently awaiting vendor approval from Regional Center. There are no residents living at the facility and no staff currently employed. Additionally, facility is currently under renovation.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 70*F. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 1-29-25. Designated medication storage area was observed to be locked.

Facility does not contain any bodies of water. LPA reviewed facility’s disaster plan to ensure regulatory compliance. 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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