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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700505
Report Date: 01/26/2023
Date Signed: 01/27/2023 08:52:14 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/27/2023 08:52 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: 5DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janet SidonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual inspection on this date.

LPA with Staff inspected physical plant including the kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in/or around the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 117 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present and operational.

LPA observed centrally stored medications locked. LPA with the assistance of the Staff reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 2 staff files, including criminal record clearances. All staff today are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Last documented fire drill was 12/29/2022. Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, no deficiencies were cited during this Inspection.

Exit interview held and a report given at the conclusion of the inspection.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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