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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700515
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:48:32 PM

Document Has Been Signed on 12/06/2022 02:48 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HLH CARE HOMEFACILITY NUMBER:
392700515
ADMINISTRATOR:DALILA DELPHINFACILITY TYPE:
735
ADDRESS:2400 BROADRIDGE WAYTELEPHONE:
(209) 956-2835
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 4DATE:
12/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:DALILA DELPHINTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on an AWOL incident, which occurred on 11/15/22. LPA'S explained purpose of visit to staff.

On 11/15/22 Resident 1 (R1) AWOL'd from the facility, R1 stated he will be going for a walk to get some air. At 4 PM staff attempted to contact R1 with no avail. Stockton PD was called and R1 was located 2.5 miles away at a restaurant.

LPA reviewed R1'S file and LIC 602 (Physician's report) and R1 is able to leave the facility unassisted. Copy taken.

No deficiencies were observed.

Exit interview conducted with Staff and a copy of report was left at facility.

Kesha.lewis@dss.ca.gov
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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