<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700981
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:14:08 PM

Document Has Been Signed on 04/02/2024 02:14 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:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:RAJENNE BOLDEN - ASSISTANT ADMINISTRATORTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted a unannounced Required 1 year Inspection Visit. LPA met with assistant administrator and explained the purpose of visit. Administrator's Certificate expires 7/27/2024.

LPA and assistant administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, and outside backyard. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 110.2 degrees Fahrenheit which is within the required range of 105 to 120 degrees. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.
Fire extinguisher last inspected on 10/24/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 3/15/2024.

LPA reviewed three resident files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA requested the following updated documents for community care licensing to be submitted via email by April 8, 2024: LIC 308 Designation of Administrator, LIC 309 Administrator Organization, LIC 400 Affidavit Regarding Client Cash Resources, LIC 610-D Emergency Disaster Plan, Copy of Administrator's Certificate, and Copy of Surety Bond with expiration date. ruth.wallace@dss.ca.gov
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today.
Exit interview conducted with assistant administrator . A copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1