392700706-1-14-2026-27-AS-NWPN-DQBVCF-20260114151904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700706
Report Date: 01/14/2026
Date Signed: 01/14/2026 03:19:11 PM

Document Has Been Signed on 01/14/2026 03:19 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 HOMES		FACILITY NUMBER:	392700706
ADMINISTRATOR/ DIRECTOR:	BISHOP, KIMBERLY		FACILITY TYPE:	735
ADDRESS:	4442 MIST TRAIL DR		TELEPHONE:	(209) 242-2583
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 5		CENSUS:	DATE:	01/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Kimberly Bishop		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 arrived unannounced to the facility at 1/14/2025 to conduct an annual visit, LPA met with administrator Kimberly Bishop, The facility is licensed for 5 male ambulatory adults aged 18-59, the current census is 3. Physical plant was inspected, including but not limited to the kitchen, bedrooms, bathrooms, storage areas, common areas, exterior and evacuation route. Facility traffic areas are well lit. Second floor and stairs, LPA pointed out some vacuumable bits on the floors. kitchen has an adequade 2 days perishable, 7 days non-perishable food supply. there is lockable storage for the sharps, toxics, and medications. First aid kit has required items, Fire extinguishers are dated 1/14/2025. The smoke/co alarm is functional. Bedrooms, have required furniture and furnishings, including mattress encasements. The door to a residents room has some punch holes in it, administrator provided that a work order is being resolved to repair the door. LPA is asking for a picture of the door being repaired by end of day 1/19/2025 to be sent to the LPA, 619-323-4509. Technical violation was issued. Bathrooms have functional hardware, the sink water temperature was measured between 105-120*F. The Drain in the sink is a little slow, LPA gave guidance to get some drain cleaner. continued on c page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MONTANA HOMES	FACILITY NUMBER: 392700706
	VISIT DATE: 01/14/2026

NARRATIVE

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Common areas and exteriors are clean, have space for activities. Required Postings (house rules, ombudsman, federal work rights, facility sketch) are up.

Evacuation route has some boxes that are approaching an obstruction. the gate itself is binding against the post, and is unable to swing freely or latch closed. LPA gave guidance to either rehang the gate or shave the post.

Meds were checked against mars for 2 clients at random, the drugs and log are found to be in accordance with each other. LPA reviewed facilitiy refusal policy, prn documentation policy, and med destruction policy.

P+I was checked against balance sheets for 2 clients at random, the cash and log are found to be in accordance with each other.

3 of 3 Client Files were reviewed including the recent medical assessments, signed admission agreements, house rules, and needs and services plans. LPA gave guidance to get consents to disclose information more often than once. client files are present and up to date.

3 of 3 staff files were reviewed, including but not limited to the continuing trainings, finger print clearance for DOJ and FBI, and the Staff files are present and up to date.

administrator files were reviewed, including the license, administrator certificate, surety bond, liability insurance, infection control plan, evacuation control plan, control of property, and franchise tax board. present and up to date.

2 Staff interviews, 1 client interviews.

no citations issued, a copy of the report was read and given to the administrator. exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC809 (FAS) - (06/04)

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