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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700074
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:34:10 AM

Document Has Been Signed on 10/11/2022 11:34 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: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:
10/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Mr. Walters TIME COMPLETED:
11:45 AM
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LPA Johnson arrived at the care facility and met with Licensee, Mr. Walters to conduct a case management visit into an incident report received into the department on 6/20/22.

The report from June of 2022 detailed an aggressive act toward another resident without injury. R1 has a history of aggressive behaviors that are identified in his current IPP, the facility is following the behavior intervention plan for non-compliance with replacement strategies, planned ignoring, etc.

The incident was reported to the department and the local police department was called. The police department did not take R1 into custody, however R1 was counseled by the police officer on seen (report number 641).

R1 has since maintained his baseline as identified in his IPP, BIP and ISP. The facility has not had an aggressive act from R1 since the incident that was reported in June of 2022.


No deficiencies were cited.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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