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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701033
Report Date: 07/14/2023
Date Signed: 07/16/2023 07:42:13 PM


Document Has Been Signed on 07/16/2023 07:42 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: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:
07/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Margaret KiagoTIME COMPLETED:
03:05 PM
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The following deficiencies, initially cited during a visit on 06/05/2023, have been cleared:




Section Cited: 87705(c)(5)Date Due: 06/19/2023
Plan of Correction:
All residents diagnosed with dementia will be scheduled with their physician and be assessed for any changes to their needs with an updated LIC 602.
Please send updated LIC 602 by POC date 		Corrections:
Cleared By Visit		Clearance Date:
07/16/2023
Section Cited: 1569.618(c)(3)Date Due: 06/06/2023
Plan of Correction:
Licensee/Administrator shall have S1 obtain re-certification in First Aid/CPR and provide documentation to CCL by fax by 6/6/2023. 		Corrections:
Cleared By Visit		Clearance Date:
07/16/2023
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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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