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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701073
Report Date: 11/05/2021
Date Signed: 11/09/2021 05:43:16 AM

Document Has Been Signed on 11/09/2021 05:43 AM - 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:MIH-5 CARE HOME, INCFACILITY NUMBER:
392701073
ADMINISTRATOR:RYAN, MICHAELFACILITY TYPE:
735
ADDRESS:9546 BISMARK PL.TELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 0DATE:
11/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caden Ryan, Facility ManagerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived to conduct an unannounced Post Licensing inspection on this date. The LPA's FAS system would not allow visited to be recorded as a Post-Licensing visit. There are yet to be client placed in the home and the home is not yet vendorized by the Regional Center.

Smoke detectors were checked and are operational. Fire extinguisher serviced in May 2021..Water was tested at 114.5 degrees. First Aid Kit in place

LPA observed the following posted in the entrance of the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Exit interview held with Mr. Ryan r and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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