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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701074
Report Date: 11/19/2021
Date Signed: 11/19/2021 04:27:53 PM

Document Has Been Signed on 11/19/2021 04:27 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-6 CARE HOME INC.FACILITY NUMBER:
392701074
ADMINISTRATOR:ELIZABETH DAVENPORTFACILITY TYPE:
735
ADDRESS:4 WEST ROBINHOOD DR.TELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Kellie Kramer, facility managerTIME COMPLETED:
04:38 PM
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On 11-19-21 at 2:57pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a post licensing inspection visit. LPA was greeted by facility manager Kellie Kramer and LPA explained the purposes of the visit. Licensee Mike Ryan was not present and gave permission for Kellie to sign in her absence and accommodate LPA.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 4-bed adult residential facility with a current census of 4. LPA was screened upon entry for temperature and asked to sign in. Facility has 4 bedrooms for resident use and a staff office. There is a dining area off the kitchen and a formal living/TV room. No obstructions to fire exits noted. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Resident rights and rights of resident. Emergency disaster plan and facility sketch updated and posted. Administrator certificate expires 04/03/2022.
The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and backyard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Facility has 30-day supply of PPE.
Water temperature reads 110.6*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply.

{Cont on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MIH-6 CARE HOME INC.
FACILITY NUMBER: 392701074
VISIT DATE: 11/19/2021
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Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Kellie Kramer and a copy of this report was left with Kellie.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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