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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 12/14/2022
Date Signed: 12/14/2022 11:36:46 AM

Document Has Been Signed on 12/14/2022 11:36 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: 4DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Blama KorhaTIME COMPLETED:
11:45 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
On 12-14-22 at 11:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding an incident report dated 11-15-22. LPA met with caregiver Blama Korha and explained the purpose of the visit. Facility manager Joseph Nimene was notified via phone and gave permission for caregiver to sign in his absence. LPA conducted follow up to a previous visit by LPA A. Johnson regarding and incident which occurred on 11-13-22. LPA interviewed caregiver and house manager, and reviewed previous technical support issued on 11-21-22 by LPA. Facility staff confirmed their acknowledgement of reporting requirements per regulations for any future events. No further incidents have occurred or have been reported since incident on 11-13-22.

Facility tour was conducted inside and out. Room temperature was at 74*F. Facility was clean and sanitary. Floors and walls were clean with no outstanding stains or physical defects noted. No obstructions to fire exits. All toxins and other dangerous items were inaccessible to residents in care. There were 2 residents on site, 2 other residents were in day program, and one staff member on duty. Adequate food supply on hand for residents in care. LPA was screened appropriately upon entry for COVID-19.

No citations issued as a result of today's case management. An exit interview was conducted with Blama Korha and a copy of this report was left with Blama.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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