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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700979
Report Date: 03/02/2021
Date Signed: 03/02/2021 04:11:25 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:ESTEEMED RESIDENTIAL CAREFACILITY NUMBER:
392700979
ADMINISTRATOR:WALTERS, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:9109 BLUE GRASS DRIVETELEPHONE:
(925) 219-2787
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:4CENSUS: 0DATE:
03/02/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christopher Walters and Imani WarrenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Eric Stone met with licensee Christopher Walters and Imani Warren, to conduct an announced Pre-licensing visit via facetime on 3/2/2021 at 1030 am. For a 4 bed ARF facility there are currently 0 residents as the facility is not yet licensed.Visitor policy, visitor logs, thermometer and sign in sheet observed near entry door. Staff and visitors enter the facility through ringing the locked front door, signs up in living room, restrooms and kitchens, all files, medical records and medications in locked cabinet in kitchen and clearly labeled.

Physical plant was clean and in good repair. Kitchen was stocked with canned and dried goods, frozen meat and perishables available. Perishables were adequate for at least 2 days with the intention of purchasing more once residents were in facility. At least 1 week worth of froze, canned, dried and panty foods including 2 bins of emergency food. Soap, sanitizer, paper towels, and hand washing signs were available at kitchen and laundry room. Fridge registered at 40, freezer at -20. Sink had hot water at 114.2.

Restrooms were stocked with personal hygiene soaps, shampoo, tooth brush, tooth paste, and deodorant as well as hand soap, sanitizer, paper towels and signs. Showers with hand rails and floor anti slip covering on floor, running water in all toilets, showers and sinks. Employees have staff room upstairs to break in. Staff is responsible to keep room clean. All residents live in single person bedrooms. Residents will have access to tv and activities.

Outside area available If weather permits chairs and tables available for residents. Gates are closed and fence in good shape. Glass windows and doors to back yard. Communal Dining large dining room with 6 chairs on table, other options included eating in rooms and main living space.

Smoke detectors were tested in each room and work, linin closet was large and fully stocked with sheets, towels and blankets. Fire extinguisher last checked 2/9/21 and 2/21/21. Comp III preformed with licensee and administrator
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Eric StoneTELEPHONE: 916-594-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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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