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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701074
Report Date: 07/19/2022
Date Signed: 07/19/2022 12:07:33 PM

Document Has Been Signed on 07/19/2022 12:07 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:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Kellie KramerTIME COMPLETED:
12:15 PM
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On 7-19-22 at 10:05am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct an annual 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 his 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. 3 of 4 residents were in day program at time of this visit. 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. LPA conducted the infection control inspection tool during visit.
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.
Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 77*F. LPA observed the facility to have adequate food supply. LPA reviewed 5 staff charts. All charts reviewed contain current first aid, COVID-19 vaccinations and criminal clearance. LPA also reviewed 4 resident charts. All charts complete at this time. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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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: 07/19/2022
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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: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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