Community Care Licensing

Document Has Been Signed on 08/30/2023 11:14 AM - It Cannot Be Edited

FACILITY NAME:	WALTERS RESIDENTIAL HOME CARE 3		FACILITY NUMBER:	392700580
ADMINISTRATOR:	CRISTOPHER WALTERS		FACILITY TYPE:	735
ADDRESS:	1335 MINE ST		TELEPHONE:	(510) 688-3552
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 4		CENSUS:	DATE:	08/29/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Joseph Nimene		TIME COMPLETED:	02:11 PM

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LPA Johnson met with Administrator to conduct POC Inspection from 809 and 809-D. The following deficiencies, initially cited during a visit on 05/19/2023, have been cleared: Section Cited: 80069(b)(1)(c1-5) Date Due: 05/20/2023 Plan of Correction: The facility will take the resident toTB test and physical completed today. Corrections: Cleared By Visit Clearance Date: 08/29/2023 Exit interview conducted . Exit interview

SUPERVISORS NAME: Stephenie Doub LICENSING EVALUATOR NAME: Albert Johnson LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023