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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700225
Report Date: 05/06/2024
Date Signed: 05/06/2024 04:42:11 PM


Document Has Been Signed on 05/06/2024 04:42 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MONA LIZAFACILITY NUMBER:
392700225
ADMINISTRATOR:SALEH, MOTHANNAFACILITY TYPE:
740
ADDRESS:1552 MIDDLE FIELD AVETELEPHONE:
(209) 910-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 6DATE:
05/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:VickyTIME COMPLETED:
03:00 PM
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On 5/6/2024 LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the complaint inspection

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited has been cleared. R1 refused to go to the Optometrist.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
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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