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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700787
Report Date: 05/05/2022
Date Signed: 05/13/2022 01:49:17 PM

Document Has Been Signed on 05/13/2022 01:49 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:LIBBIE CARE HOMEFACILITY NUMBER:
392700787
ADMINISTRATOR:RAM, AVINESHFACILITY TYPE:
735
ADDRESS:558 E EDISON STTELEPHONE:
(209) 824-5993
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 5CENSUS: 3DATE:
05/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Avinesh RamTIME COMPLETED:
03:00 PM
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Unannounced plan of correction visit made out to this facility on 05/05/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua and were met by the facility live-in caregiver Avinesh Ram who was briefly interviewed.
Current census was 3 residents of which one resident was still at their respectable day program.
The purpose of this visit was to follow up on the deficiencies that were cited on a prior visit.
Tour of the facility was conducted.

The following items were reviewed to make sure that they were brought into compliance:

Facility representative stated that proof of the transfer clearance will be completed and submitted into CCL for review by this LPA.

Facility representative stated the backyard area will be cleaned and cleared of any weeds and unused items so that all walkways and paths are kept free and clear at all times. A statement of correction, with photos of cleaned and cleared backyard area, to be completed and submitted into CCL.

Proof of correction letters were printed and a copy was left with the facility caregiver at this time.

There were no deficiencies observed or cited during today's plan of correction visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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