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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700505
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:33:14 AM

Document Has Been Signed on 11/19/2021 11:33 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:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Aaron TanTIME COMPLETED:
11:45 AM
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LPA Johnson arrived at the care facility and met with Aaron and Cleo to conduct a case management visit into an incident report received on 11/12/2021.

R1 and R2 have not received Personal and Incidentals (P&I) for three months this includes the facility not being paid the SSI portion of the rent. The facility has notified stakeholders of the fiduciary abuse that has happened as a result of R1 and R2's parent (MS) being the payee.

LPA reviewed P&I balances for R1 and R2. The account was accurate and it was confirmed that they have not received money since September of 2021.

LPA advised the facility to report this suspected Fiduciary abuse on a SOC 341 form (Suspected Abuse Form) and submit it to Adult Protective Services, Local Ombudsman, Valley Mountain Regional Center and Community Care Licensing.

No deficiencies were cited.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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