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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700939
Report Date: 03/02/2023
Date Signed: 03/02/2023 03:28:03 PM

Document Has Been Signed on 03/02/2023 03:28 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:LIFE CARE HOMEFACILITY NUMBER:
392700939
ADMINISTRATOR:SINGH, GURPRITFACILITY TYPE:
735
ADDRESS:4642 EWS BLVDTELEPHONE:
(209) 479-4346
CITY:STOCKTONSTATE: CAZIP CODE:
95231
CAPACITY: 6CENSUS: 0DATE:
03/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gurprit SinghTIME COMPLETED:
03:30 PM
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On 3/2/23 at approximately 3pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. There was nobody at the facility. LPA Jensen called Licensee an spoke to Gurprit Singh. The Licensee confirmed that there are no clients and they have not yet admitted their first resident. The Licensee stated that he believes he will have his first client in approximately 2 months time. The Licensee stated that he will call the Department to schedule the required annual visit shortly.

This annual inspection will require a continuation. In addition, the facility address needs to be corrected to 4642 EWS Woods Blvd, Stockton, CA 95206.

A copy of this report is being emailed for signature to the Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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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