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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700178
Report Date: 12/13/2021
Date Signed: 12/13/2021 03:27:48 PM

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:DULAY GUEST HOME 4FACILITY NUMBER:
392700178
ADMINISTRATOR:MENDOZA, LOVEMINDAFACILITY TYPE:
740
ADDRESS:653 CHICAGO AVETELEPHONE:
(209) 482-8230
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
12/13/2021
TYPE OF VISIT:POCANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Loveminda MendozaTIME COMPLETED:
02:48 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility and met Monica to conduct an unannounced health and safety check and a POC visit from the annual completed on 9/08/2021.

Administrator submitted required corrections as required by due date.

POC's corrected

Deficiencies cleared

POC letter printed.


Exit interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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