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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700706
Report Date: 03/15/2024
Date Signed: 03/15/2024 04:15:31 PM

Document Has Been Signed on 03/15/2024 04:15 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:MONTANA HOMESFACILITY NUMBER:
392700706
ADMINISTRATOR:BISHOP, KIMBERLYFACILITY TYPE:
735
ADDRESS:4442 MIST TRAIL DRTELEPHONE:
(209) 242-2583
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 5CENSUS: 3DATE:
03/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:BISHOP, KIMBERLYTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted a case management inspection of MONTANA HOMES. LPA met with BISHOP, KIMBERLY to ensure the facility is in compliance with applicable statutes and regulations.

During the visit, the LPA conducted interviews with staff, the licensee, the Administrator.

The LPA reviewed staff/resident files and resident medications and observed all medications to be accounted for and locked and inaccessible to residents in care.

The LPA conducted a tour of the physical plant and observed the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations.

Based on interviews, file/medication reviews, and observation of the physical plant, it appears the facility is operable at this time.

An exit interview was held with BISHOP, KIMBERLY and a copy of the report was provided.



SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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