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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 01/30/2023
Date Signed: 01/30/2023 03:14:28 PM

Document Has Been Signed on 01/30/2023 03:14 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
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:
01/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Joseph NimeneTIME COMPLETED:
03:15 PM
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LPA Albert Johnson arrived at the facility today to conduct a case management visit to follow up on an incident report that was submitted to Community Care Licensing.

The report from January of 2023 detailed an aggressive act toward another resident without injury. R1 has a history of aggressive behaviors that are identified in his current IPP, the facility is following the behavior intervention plan for non-compliance with replacement strategies, planned ignoring, etc.

The incident was reported to the department and VMRC. R1 requested to go to his father's house and packed his items. The facility contacted his father and confirmed that R1 was able to come home. The facility took R1 to his father's house. This is similar to his last placement and how he left the other facility. On this date, R1's father came by and picked up the remainder of his items today.

R1 stated that he is not happy being in the current placement and wants to move. Historically, this situation does not workout for R1 or his father.

No deficiencies were cited.

A copy of this report and exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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