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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700729
Report Date: 05/24/2022
Date Signed: 05/24/2022 03:02:13 PM


Document Has Been Signed on 05/24/2022 03:02 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:YANNICA GUEST HOMEFACILITY NUMBER:
392700729
ADMINISTRATOR:MARTIN, MAXIMAFACILITY TYPE:
740
ADDRESS:2329 DIAMOND OAKS STREETTELEPHONE:
(510) 366-6585
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
05/24/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Rufina AlvarezTIME COMPLETED:
03:17 PM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual licensing inspection conducted on 2/17/2022. LPA was informed during the visit that Administrator had a family emergency.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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