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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700264
Report Date: 01/06/2022
Date Signed: 01/12/2022 08:48:57 AM

COMPREHENSIVE INSPECTION
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:JEWELL HOME CAREFACILITY NUMBER:
392700264
ADMINISTRATOR:RALH, MONICAFACILITY TYPE:
740
ADDRESS:1141 S. VAN BUREN STREETTELEPHONE:
(209) 323-4972
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
01/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Annie BynunTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with Annie Bynun explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.9 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 6 resident and 2 staff files, including criminal record clearances. Fire drill was completed. All staff are fingerprint cleared. First aid kit was checked and is complete.

No deficiencies were cited as per Title 22 Regulations and the Health and Safety Code.

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

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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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