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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700505
Report Date: 12/13/2022
Date Signed: 12/13/2022 05:44:53 PM

Document Has Been Signed on 12/13/2022 05:44 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: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: DATE:
12/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:57 PM
MET WITH:A. TanTIME COMPLETED:
05:43 PM
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LPA Albert Johnson made an unannounced Safety check to the facility to follow-up on the placement of R1.

LPA observed the R1 watching T. V. with staff. The resident appears to be safe and continent. R1 did come with personal items and P&I funds.

LPA reviewed the medication administration record and confirmed that medications are being given as ordered. The facility made adjustments to the bubble packs to ensure consistence with the administration of the medications provided.

No deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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