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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701073
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:23:44 PM

Document Has Been Signed on 09/15/2022 04:23 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:MIH-5 CARE HOME, INCFACILITY NUMBER:
392701073
ADMINISTRATOR:WHITNEY MONTIJOFACILITY TYPE:
735
ADDRESS:9546 BISMARK PL.TELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Whitney MontijoTIME COMPLETED:
03:21 PM
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Licensing Program Analysts Albert Johnson and Kesha Lewis arrived to conduct an unannounced Case Management visit. LPAs met with Whitney M.

Community Care Licensing received incident reports on 08/14/2022 regarding a an AWOL. LPA requested residents files for review. LPA spoke with Administrator regarding the incident reports.

LPA did obtained copies of resident records. R1 is allowed to go into the community without assistance. This is identified in R1's IPP. R1 is allowed to go into the community without assistance.

Per California Code of Regulations and Health and Safety Code, Title 22.

No deficiencies were issued today.

Exit interview. Copy of report provided to facility representative.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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