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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700979
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:42:50 PM

Document Has Been Signed on 02/10/2023 03:42 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:ESTEEMED RESIDENTIAL CAREFACILITY NUMBER:
392700979
ADMINISTRATOR:WALTERS, CHRISTOPHERFACILITY TYPE:
735
ADDRESS:9109 BLUE GRASS DRTELEPHONE:
(925) 219-2787
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 4DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Christopher WaltersTIME COMPLETED:
03:55 PM
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On 2-10-23 at 1:59pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct an annual inspection. LPA met with Administrator Christopher Walters and facility administrator Imani Warren and explained the purpose of the visit. Administrator Certificate expires 11/28/23.

LPA inspected the physical plant including but not limited to the kitchen, dining room, 4 resident bedrooms; 2 resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 4. Dining area leads off from the kitchen area. LPA also conducted the infection control domain tool.

Facility has submitted a COVID-19 mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
There is a locked storage for medications and toxins. Food supply is adequate for two day perishable and seven day non-perishable. Water temperature measured between 105*F and 120*F in the bathrooms and room temperature reads 72*F. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire alarms were checked and found to be in working order. Fire Extinguishers updated 5/3/22. LPA observed an adequate amount of linens and found the first aid kit to be complete.
LPA reviewed 4 resident records and 5 staff records. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed and have current first aid certificates. All health screen and TB results are current for staff..
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and report and appeal rights were given to Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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