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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700893
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:00:36 PM

Document Has Been Signed on 11/04/2021 03:00 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:SHADMAN HOUSEFACILITY NUMBER:
392700893
ADMINISTRATOR:SHADMAN, KIRSTENFACILITY TYPE:
735
ADDRESS:3832 CHERRYLAND AVETELEPHONE:
(209) 451-4595
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 5CENSUS: 4DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kristen ShadmanTIME COMPLETED:
03:15 PM
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On 11/4/2021 at 1:45pm Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection. LPA contacted Licensee prior to today's inspection who confirmed no staff or clients have tested positive or shown symptoms within the past 10 days. LPA met with Designated Staff Assistant Administrator and was allowed entry into the facility that is licensed to serve a total capacity of 5, today's census is 4. Six of Six staff observed on site with criminal record clearance in Licensing Information System. LPA observed Assistant Administrator Certificate expires on 4/8/2022.

LPA interacted with a random number of residents during this visit and observed residents. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas to be clean and in good repair. The temperature inside the facility was measured at 74*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 108*F within regulatory range of is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications, toxins, and knives to be locked inaccessible to residents. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

Facility handles P & I monies, LPA observed the log and there is no commingling of funds. LPA observed the facility conducts fire drills documented monthly, last fire drill conducted on today's date prior to LPA's arrival.

Continued on 809 C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SHADMAN HOUSE
FACILITY NUMBER: 392700893
VISIT DATE: 11/04/2021
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Continued from 809.

LPA observed fire extinguisher last inspected on 3/2/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA 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. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and hand washing signs. LPA observed 30 day supply of PPE stored is stored.

The facility has an approved Mitigation Plan.

Upon a file review the following items were discussed to be submitted to LPA by 11/9/2021:
Designation of Administrative Responsibility LIC308
Qualifications of Administrator
Personnel Report LIC500
Emergency Disaster Plan LIC610D

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC809 (FAS) - (06/04)
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