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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700939
Report Date: 02/16/2021
Date Signed: 02/16/2021 02:59:13 PM

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:
02/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Gurpeit SinghTIME COMPLETED:
03:00 PM
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Introduction: Licensing Program Analyst (LPA’s) Eric Stone, and licensee applicant Gurpeit Singh conducted an unannounced prelicensing visit over the phone due to covid 19 guidelines on 2/16/2021 via Microsoft teams at 01:30pm. Upon innital call licensee applicant was in facility. As of today, census is 0 residents.

Visitor policy and visitor logs not yet avalible and noted by lpa Staff and visitors enter the facility through ringing the locked front door, sanitizing supplies would be avalible in front station near front door. Hand sanitizer was available in the front entrance. Signs not yet up needed in dining room, front room, kitchen and bathroom and main living space.

Physical plant was clean and in good repair. Floor was tile, and in good condition. Fire extinguisher with no date on it observed. Water tempeture measured at 111.8 thermostat set 68. There was 2 full cabnits of nonperishable foods. Cleaner under locked sink was pinsol, clorolx bleach, Lysol. Fridge was set to 40 degrees and freezers at 0 degrees. Multiple First aid kit, w/ scissors and tweezers, wound cleaning, banadages, pain and allergy pills, gloves., thermoitor, blood pressure cuffm, sharps container. Stehiscope, to go wipes. Medical records and medications cabnits. Behind locked doos, bins with labels. Laundry room, locked, with cleaning supplies and ppe. Bed rooms, individual rooms, w/ closet, bed, chair, lamp and night stand and ceiling light, Double bed room with similar set up 3 feet head to toe orientation corrected during call. Restroom, sinks work shower and toilet works, grab bar by toilet, grab bar and slip mat in shower. Windows in good shape and repair. Garage for activity room and rainy day activities. Night lights in facility. PPE avalible throught house. All residents will live in single bed rooms with a single 2 person bedroom. Communal Dining Meals were served in dining room with 2 chairs on table, other options included eating in rooms and main living spaces tv trays used. Chairs not spaced 6 feet apart per covid per cautions.


Comp III completed with Licensee Gurpeit Singh Exit interview conducted with Gurpeit Singh signed and retuned via email to Eric Stone eric.stone@dss.ca.gov
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Eric StoneTELEPHONE: 916-594-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
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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