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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700074
Report Date: 10/08/2021
Date Signed: 10/08/2021 03:23:22 PM

Document Has Been Signed on 10/08/2021 03:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 2FACILITY NUMBER:
392700074
ADMINISTRATOR:WALTERS, MOSES SRFACILITY TYPE:
735
ADDRESS:4717 WHITE FORGE DRIVETELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 6DATE:
10/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Walter MosesTIME COMPLETED:
03:25 PM
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LPA Johnson arrived at the care facility and met with Administrator to conduct a case management visit into an incident report received into the department on 10/05/2021.

R1 was reported to have bruises on his arm. The origin of the bruises was not reported by the care home, because it was an incident that involved aggressions between to residents with known behaviors that included: pinching, verbal aggression, property damage and aggressive acts towards others.

LPA Johnson was informed by Administrator and staff (Natasha) that R2 has a behavior plan that addresses the incidents of pinching and R1 will make threats toward R2 or verbally redirect R2. When these incidents occur R2 will attempt to/or have success in pinching R1 when they are close to each other.

The bruises identified in the report were obtained on 10/4/2021, as a result of an aggressive act between R1 and R2.

No deficiencies were cited today.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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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