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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700825
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:28:07 PM

Document Has Been Signed on 05/31/2022 01:28 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:CHAMPION RESIDENTIAL IIFACILITY NUMBER:
392700825
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:577 SUTHERLAND DR.TELEPHONE:
(209) 420-9932
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 3DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jamesha Boyd - Licensee/AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct a Required – 1 Year Inspection Visit. LPA met with Licensee/Administrator and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 clients.
LPA did not interact with residents during this visit, all were in adult day programs. The physical plant was toured inside and outside to ensure the safety of the residents. LPA Wallace observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. The temperature inside the facility was measured at 74 degrees F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 109.3 F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the facility conducts fire drills monthly. LPA Wallace observed fire extinguisher which expires 08/10/22. LPA inspected smoke and carbon monoxide detectors, central heating and air in the facility.
LPA Wallace observed the centrally stored medications area to be locked and inaccessible to clients.
The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed (2) staff files. All staff is fingerprint cleared and associated to the facility staff have current First Aid or CPR certifications on file. LPA reviewed (3) resident files and all documents were current for Community Care Licensing (CCL). Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, Sketch, See Something Say Something poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

LPA requested the following documents to be submitted by June 31,2022:
Copy of Administrator Certificate, Copy of Deed Designation of Facility Responsibility LIC 308, Affidavit Resource Regarding Client Cash Resources LIC 400, Facility, Personnel Report Summary LIC 500, and Emergency Disaster Plan LIC 610E.
Based on today's inspection, no deficiencies are being cited from Title 22 Regulations. Exit interview held with Administrator and copy of reports left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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