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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700505
Report Date: 09/28/2021
Date Signed: 09/29/2021 08:20:29 AM

Document Has Been Signed on 09/29/2021 08:20 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:MCCOOK CARE HOMEFACILITY NUMBER:
392700505
ADMINISTRATOR:TAN, AARON ANTHONY LFACILITY TYPE:
735
ADDRESS:2943 MCCOOK WAYTELEPHONE:
(209) 298-7171
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
09/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Samson AboboTIME COMPLETED:
03:00 PM
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LPA met with Samson to conduct a case management visit to follow up on an incident report dated 9/10/2021.

R1 was sent out to the ER on 8/23/2021 for allergic reaction to coffee cream which has milk by produces that R1 is allergic to. R1 also has been having an increase in behavior episodes including aggression, attempting to pull out other residents G-tubes, inappropriate sexual attempts with his peers.

LPA has requested copies of R1's discharge papers, most recent medication increase and IPP.

No deficiencies were cited at the visit today.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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