<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700213
Report Date: 12/29/2021
Date Signed: 12/29/2021 02:56:53 PM

Document Has Been Signed on 12/29/2021 02:56 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:MIH CARE HOMEFACILITY NUMBER:
392700213
ADMINISTRATOR:MAI XIONGFACILITY TYPE:
735
ADDRESS:7514 CORAL LNTELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 3DATE:
12/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Mai XiongTIME COMPLETED:
02:56 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12-29-21 at 1:57pm, LPA Michael Bilger arrived unannounced to conduct a case management visit for an incident occurring on 12/1/2021. LPA met with Administrator Mai Xiong and explained the purpose of the visit. Facility was toured inside and out. Temperature was at 77*F. Facility was clean and sanitary. Facility also contained adequate food supply for clients in care. All sharp objects and toxins are inaccessible to clients in care. There was 1 staff for 2 clients present during the visit. Administrator was also present. No obstructions to fire exits noted inside or out. Based on incident report, resident1 (R1) left facility on 12-1-21 at approximately 6:00am to spend the night at a friends house, and at approximately 2:00pm R1 communicated to Administrator her desire to not return via text. Administrator also found a written letter from R1 stating her intentions to not return to facility. LPA also reviewed physician's report and Individualized Program Plan (IPP) for R1 which states R1 is able to leave facility unassisted. R1's chart was reviewed and contained all appropriate documentation up to date. R1 was admitted 9-29-2020. After resident exited facility, Administrator contacted police to file missing person's report and notified regional office of incident, as well as service coordinator for R1. IPP also states R1 has a history of unstable living environments.

As a result of today's visit, it is determined that facility followed reporting requirements and communication attempts to keep client safe. R1 has since picked up personal belongings. No deficiencies were observed as a result of this case management visit. An exit interview was conducted with Mai Xiong and a copy of this report was left with Mai.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1