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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700410
Report Date: 09/07/2023
Date Signed: 09/07/2023 11:17:01 AM

Document Has Been Signed on 09/07/2023 11:17 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: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: 3DATE:
09/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:C. SoaresTIME COMPLETED:
11:02 AM
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to conduct a case management visit. LPA met with Administrator /Licensee and explained the purpose of today's visit.

The purpose of today's visit is in response to following up on bed bug pest control treatment.

LPA toured the facility, the treatment has not been completed, and residents are back in the facility. There is pest control treatment that is still needed. LPA obtained copies of the service agreement.

All residents appear to be healthy and clean.

An exit interview was conducted, and a copy of the 809 report was given to the facility.

No deficiencies were cited at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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