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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700424
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:35:15 PM

Document Has Been Signed on 01/09/2024 01:35 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:
392700424
ADMINISTRATOR:DAUGHERTY, MARIA MICHELLEFACILITY TYPE:
735
ADDRESS:1920 S STOCKTON STTELEPHONE:
(209) 469-3668
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:MARIA DAUGHERTY - ADMINISTRATORTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection visit on this date. LPA met with administrator and explained the purpose of the visit.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. 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 113.4 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. Carbon dioxide monitor present. Fire drill was last conducted on 12/13/2023.

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed two resident and two staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit.

Exit interview with administrator. Copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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