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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700729
Report Date: 10/05/2023
Date Signed: 10/26/2023 10:30:20 AM


Document Has Been Signed on 10/26/2023 10:30 AM - 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:
10/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Rambuyon,TIME COMPLETED:
03:00 PM
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LPA Johnson arrived at the care facility unannounced to conduct a case management visit into an incident report received.

R-1 AWOL'd from the facility on 9/11/23 and has not returned.

According to R1's Physicians report, the area regarding "is allowed to leave the facility unassisted" is blank.

The Police were called and stated that if he is not conserved he can leave any time he wants. LPA spoke with Staff about the plans for R1 if he returns. There are no plans.

No deficiencies were cited on today's date.

Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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