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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700074
Report Date: 04/26/2023
Date Signed: 07/06/2023 01:18:58 PM

Document Has Been Signed on 07/06/2023 01:18 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
SACRAMENTO AC/SC, 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:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tanneh Koayen, Facility ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Tanneh Koayen, Facility Manager. As an administrator she currently holds a certificate (#6030594735) that expires on 07/09/2023.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms of which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 107-degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/25/2023. First aid kit was observed to be complete. Fire drill was last conducted on 04/11/2023.

LPA reviewed 2 of 6 staff records and 2 of 6 client record. All staff files reviewed had current CPR training.

The following forms to be updated and submitted to CCL by 05/04/2023.

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

No deficiencies were cited during this inspection.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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