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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700578
Report Date: 10/09/2023
Date Signed: 10/09/2023 10:42:35 AM

Document Has Been Signed on 10/09/2023 10:42 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:KAVERE SERVICES-LIFE SKILLS PROGRAMFACILITY NUMBER:
392700578
ADMINISTRATOR:GULLEY, AMANDAFACILITY TYPE:
735
ADDRESS:3716 JAGGER LNTELEPHONE:
(209) 451-1003
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 5CENSUS: 3DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amanda Gulley - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required annual inspection visit. LPA met with Administrator and explained purpose of visit. Administrator's Certification expires 11/17/2023. There are currently three residents who reside at this home.

LPA and administrator inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for two day perishable and seven day nonperishable.

Fire extinguisher was last inspected April 13, 2023. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 112.4 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA confirmed all staff present is background cleared.

LPA reviewed three staff and two resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA received the following updated documents : LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, and copy of current Administrator’s Certificate.

Exit interview conducted with Administrator. A copy of report and LIC 811 (Confidential Names) left at facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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