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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701033
Report Date: 07/12/2021
Date Signed: 07/12/2021 11:20:10 AM

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:ST. RITA CARE HOMEFACILITY NUMBER:
392701033
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:3478 LADD TRACT CT.TELEPHONE:
(650) 465-2526
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 0DATE:
07/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Catherine TalongwaTIME COMPLETED:
11:32 AM
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Licensing Program Analyst (LPA) Albert Johnson conduct an announced Pre-Licensing Inspection.

This facility will be licensed for a capacity of 6 residents and LPA was also informed that this will not be a Regional Center funded facility. LPA met with Administrator who assisted with today’s inspection.

LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are no residents at this time. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. LPA observed the area that food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days will be maintained on the premises.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed a centrally stored medication area, which will be locked at all times.

LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility. Component III was conducted - License pending.

Exit interview held, copy of the report will be emailed to the Applicant.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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