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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700665
Report Date: 10/14/2024
Date Signed: 10/14/2024 02:03:14 PM

Document Has Been Signed on 10/14/2024 02:03 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LAV MANORFACILITY NUMBER:
392700665
ADMINISTRATOR/
DIRECTOR:		JOYCE VILLANUEVAFACILITY TYPE:
735
ADDRESS:6411 KERMIT LANETELEPHONE:
(209) 473-4250
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 3DATE:
10/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:VillanuevaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 10/14/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannouced visit/ health and safety check for R1 who was sent out to the ER on 10/1/2024.

LPA reviewed discharge paper work from St. Joseph's ER and conducted a Health and Safety check including food supply, physical plant and staffing. Based on this inspection/visit the facility is in compliance.


R1 was sent out to the ER for Gastro -acute management. R1 was seen and sent back the same day. The administrator has scheduled an appointment for follow-up to the ER visit that was conducted on 10/2/2024 for R1.


No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Code
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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