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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700932
Report Date: 08/01/2022
Date Signed: 08/01/2022 11:49:39 AM

Document Has Been Signed on 08/01/2022 11:49 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:BUENA VIDA CARE HOME IIFACILITY NUMBER:
392700932
ADMINISTRATOR:LADION, PIERRE J.FACILITY TYPE:
735
ADDRESS:1143 LUNA LANETELEPHONE:
(209) 464-1668
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
08/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Dardanela AllasTIME COMPLETED:
11:30 AM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit conducted on 06/2022 .

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

Facility was provided a POC cleared letter for cleared citations.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
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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