<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700505
Report Date: 02/04/2024
Date Signed: 02/04/2024 11:17:10 AM

Document Has Been Signed on 02/04/2024 11:17 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:
02/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:CLEO TAN - ADMINISTRATORTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 year Annual Inspection Visit. LPA met with administrator and explained purpose of visit.


LPA and administrator inspected physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature measured at 115.6 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were inspected on 12/26/2023. Smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. Common touch surfaces are cleaned after each use. Fire drill last conducted on 1/31/2024.
LPA reviewed four resident and five staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

LPA requested the following updated documents to be submitted via email to community care licensing by February 12, 2024: LIC 308, LIC 500 - Personnel Report, Copy of Surety Bond, and Copy of Administrator Certificate. ruth.wallace@dss.ca.gov
Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection.

An exit interview was conducted with administrator. A copy of this report and LIC 811(Confidential Names)

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1