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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700178
Report Date: 03/21/2023
Date Signed: 03/21/2023 11:30:35 AM


Document Has Been Signed on 03/21/2023 11:30 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: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: 4DATE:
03/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:DeloresTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility and met Delores to conduct an unannounced plan of correction visit and safety check from the annual completed.

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: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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