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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701074
Report Date: 06/09/2023
Date Signed: 07/22/2023 06:06:00 AM

Document Has Been Signed on 07/22/2023 06:06 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MIH-6 CARE HOME INC.FACILITY NUMBER:
392701074
ADMINISTRATOR:KELLIE KRAMERFACILITY TYPE:
735
ADDRESS:4 WEST ROBINHOOD DR.TELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Kelly Krammer AdministratorTIME COMPLETED:
05:15 PM
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On 6/9/23 at 2:15pm Licensing Program Analysts (LPA) Jennifer Fain and Maja Jensen conducted an unannounced Required 1 Year Annual Inspection. LPAs met with Kelly Kramer Administrator and explained purpose of visit.

LPAs and administrator toured both indoors and outdoors of facility. LPAs observed the physical plant, food service, medications, client and staff records. The outside of the facility was observed to be in good repair and safe for residents. The outdoors had a shaded seating area and activities for the residents including but not limited to gardening, frisbee golf, basketball and large format connect four. The inside of the facility was observed to be in good repair. Bathrooms and showers were sanitary and in good repair. The hot water temperature was measured at 106 degrees Fahrenheit which is within the required range of 105-120 degrees Fahrenheit. Facility was maintained at a comfortable temperature. Required amounts of stored and perishable foods were present. Bedrooms were observed to be in good repair. Bedding, storage and lighting were adequate. Medications, chemicals, and toxins were inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were tested and operational. Facility is equipped with a central pull fire alarm. Fire extinguisher was fully charged and inspected on 3/8/23. First aid kit was fully stocked for use. Facility license was openly posted for viewing. Administrator’s Certificate expires 4/29/24.

4 staff and 4 resident’s records were reviewed and were in good order.

Continued on 809C
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MIH-6 CARE HOME INC.
FACILITY NUMBER: 392701074
VISIT DATE: 06/09/2023
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LIC 500, Surety Bond, Liability Insurance and Lease Agreement were requested and copies were given to LPA Jensen.

The CARE Tool was used during this inspection and the facility was found to be in substantial compliance.

An exit interview was held with administrator and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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