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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700640
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:34:41 PM


Document Has Been Signed on 03/02/2023 02:34 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:COURTYARD AT RIO LAS PALMAS, THEFACILITY NUMBER:
392700640
ADMINISTRATOR:GUERRERO, LIZETHFACILITY TYPE:
740
ADDRESS:877 EAST MARCH LANETELEPHONE:
(209) 957-4711
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:80CENSUS: 58DATE:
03/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jennifer Almendarez and Lizeth GuerreroTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management regarding a an LIC 624A received on 2/1/23 for a death that is reported as occurring on 12/31/23. LPA Jensen met with Jennifer Almendarez, Resident Care Coordinator, and Lizeth Guerro, Executive Director.

LPA Jensen interviewed both the Resident Care Coordinator and the Executive Director and it was determined that Resident 1 (R1) actually passed away on 1/31/23 and the date on the LIC 624A was a typing error. Given the actual date of death as verified by records and interviews, the reporting time frames were met.

There are no compliance concerns at the facility at this time.

An exit interview was conducted and a copy of this report was provided.


SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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