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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700665
Report Date: 09/24/2022
Date Signed: 09/24/2022 12:33:16 PM

Document Has Been Signed on 09/24/2022 12:33 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:LAV MANORFACILITY NUMBER:
392700665
ADMINISTRATOR:ARVIN VILLANUEVAFACILITY TYPE:
735
ADDRESS:6411 KERMIT LANETELEPHONE:
(209) 473-4250
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 3DATE:
09/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Manager Joyce Villanueva TIME COMPLETED:
12:45 PM
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
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a required 1-year Annual inspection. LPA was met Facility Manager Joyce Villanueva and explained the reason for the visit. Census 3

LPA Lund and Facility Manager Joyce Villanueva toured the facility inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, restrooms, bedrooms, and common living areas to be in good repair. LPA observed items stored not in use in shed and side yard including wheelchairs and client equipment. LPA observed the centrally stored medications, toxins, and knives to be locked inaccessible to residents. The first aid kit was found in compliance.

LPA observed fire extinguisher last inspected on 6/3/2022, pull alarm system, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash can and 30- day supply of PPE stored.


No deficiencies were cited during this visit. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2022
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