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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 06/07/2022
Date Signed: 06/28/2022 10:59:11 AM

Document Has Been Signed on 06/28/2022 10:59 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:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Joseph NimeneTIME COMPLETED:
03:45 PM
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LPA Johnson arrived at the care facility and met with to conduct a case management visit into an incident report received regarding an AWOL. The care facility did file a police report and have informed all appropriate parties and agencies.

On 5/21/2022 R1 AWOL'd from the facility, Staff followed R1 on foot, but R1 fled from staff on his motorized bike. Staff notified the administrator, and called the Stockton Police Department. The police made staff aware that R1 contacted them stating he didn't feel safe, & the Police took R1 to a local shelter.

R1 is currently at the shelter located at 545 W Sonora St.Stockton Resident involved has not returned. The resident moved to another facility.

Obtained by LPA Johnson were copies of residents file information.

No deficiencies cited during this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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