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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700410
Report Date: 04/08/2022
Date Signed: 04/08/2022 02:41:20 PM

Document Has Been Signed on 04/08/2022 02:41 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:A.J GUEST HOMEFACILITY NUMBER:
392700410
ADMINISTRATOR:SOARES, CONCEPCION BFACILITY TYPE:
735
ADDRESS:1854 ERICKSON CIRTELEPHONE:
(209) 943-1381
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:C Soares on the phoneTIME COMPLETED:
03:00 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
LPA Johnson arrived to the facility unannounced to conduct a Case management incident/ Inspection related to addendum added to R1's program plan.

LPA reviewed R1 addendum and confirmed that the facility will update the facility file to reflect the changes to the plan for R1. The facility was at an outing and was unable to return to the facility. LPA spoke with Licensee via phone.

No deficiencies were cited on today's date.

LPA was able to obtained copies of resident's addendum via email. LPA also delivered Antigen Testing Kits.


Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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