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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701051
Report Date: 08/16/2021
Date Signed: 08/17/2021 09:42:36 PM

Document Has Been Signed on 08/17/2021 09:42 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:BEAVERS RESIDENTIAL CARE HOMEFACILITY NUMBER:
392701051
ADMINISTRATOR:ZENO-BEAVERS, MONICAFACILITY TYPE:
735
ADDRESS:5137 SHIPWHEEL DRIVETELEPHONE:
(209) 594-0590
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 0DATE:
08/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Monica Zeno-Beavers TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson made an announced Pre-licensing Inspection. LPA met with Administrator who assisted with today’s inspection.

LPA met with the facility's Administrator. This facility will be licensed as a 6 bed ambulatory residential facility, LPA was also informed that this will be a Regional Center funded facility.

LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. There are no residents at this time. The kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms are clean and in good repair. The knives/sharps area will be locked. There is the required furniture, and lighting throughout the facility. 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. The centrally stored medication area will be locked at all times.

There are fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility. LPA shared information for the recall of the combination detectors.

Component III was completed.

Exit interview conducted and copy of this report emailed and a copy of the report will be sent to the applications unit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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