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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700173
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:00:07 PM

Document Has Been Signed on 04/12/2022 04:00 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:PEOPLE'S CARE WILLORAFACILITY NUMBER:
392700173
ADMINISTRATOR:SIMON, ARNEATHAFACILITY TYPE:
735
ADDRESS:949 WILLORA RDTELEPHONE:
(209) 957-3662
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 5CENSUS: 5DATE:
04/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Arneatha SimonTIME COMPLETED:
04:00 PM
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On 4/12/22 Licensing Program Analyst Maja Jensen made an unannounced case management visit. LPA Jensen met with Administrator Arneatha Simon and explained the purpose of today's visit

LPA Jensen obtained copies or photos of MAR dating back to 3/25/22, Pre-Placement Appraisal LIC 603, Regional Center Behavioral Support Plan and Update and Physician's Report LIC 602..

Administrator advised LPA Jensen she was sending a revised incident report as the wrong dates were erroneously recorded on the original report.

LPA Jensen will follow up with facility at a later date after review of the requested documents.

No deficiencies were cited as a result of today's visit. An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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