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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700981
Report Date: 03/10/2023
Date Signed: 03/19/2023 09:23:13 PM

Document Has Been Signed on 03/19/2023 09:23 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:PHOENIX HOUSE ARF, INCFACILITY NUMBER:
392700981
ADMINISTRATOR:CAMPBELL, SCOTTFACILITY TYPE:
735
ADDRESS:2428 WARLOW LANETELEPHONE:
(209) 351-4808
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 5CENSUS: 5DATE:
03/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Angela RobinsonTIME COMPLETED:
01:55 PM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during an annual survey conducted on 2/24/2023.

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiencies have been cleared.

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


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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