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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701033
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:12:39 PM


Document Has Been Signed on 09/11/2023 04:12 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: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: 4DATE:
09/11/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:O. KellyTIME COMPLETED:
02:45 PM
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The following deficiencies, initially cited during a visit on 08/25/2023, have been cleared:

Section Cited: 87465(c)(2)Date Due: 08/26/2023
Plan of Correction:
Facility Administrator will perform an audit of the medications to ensure accuracy of counts and administration. 		Corrections:
Cleared By Visit		Clearance Date:
09/11/2023
Section Cited: 87468.1(a)(3)Date Due: 09/08/2023
Plan of Correction:
The facility will work with R1 and locate an area that will allow for privacy to allow R1 to conduct business without interruption.		Corrections:
Cleared By Visit		Clearance Date:
09/11/2023

Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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