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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700663
Report Date: 09/24/2021
Date Signed: 09/25/2021 02:46:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/25/2021 02:46 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:MIH-4 CARE HOME INCFACILITY NUMBER:
392700663
ADMINISTRATOR:XIONG, MAIFACILITY TYPE:
735
ADDRESS:9815 KOALA CTTELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 4CENSUS: 0DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:M RyanTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection.

There are no residents in care at this time. The facility is waiting to be vendorized by Valley Mountain Regional Center.

LPA inspected the physical plant. LPA observed sufficient furniture and lighting throughout the facility.

Fire extinguishers and Smoke detectors are operational. LPA observed where centrally stored medications will be locked.

First aid kit is complete. LPA observed carbon monoxide detectors in the facility.

No deficiencies.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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