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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701073
Report Date: 02/06/2024
Date Signed: 02/06/2024 11:55:55 AM

Document Has Been Signed on 02/06/2024 11:55 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 3DATE:
02/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:WHITNEY MONTIJOTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding two incident reports received dated 02/01/2024 . LPA explained purpose of visit to the administrator.

The incident report was regarding a resident death and resident breaking the window and the facility bedroom door. LPA reviewed incidents reports and facility provided R1'S IPP, care notes and physician's report (602). LPA also interview administrator. All incidents were reported on time and to the correct departments. Death report not available at this time.

Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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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