<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701090
Report Date: 10/22/2021
Date Signed: 10/22/2021 12:17:09 PM

Document Has Been Signed on 10/22/2021 12:17 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:RIVMAGS CARE HOME LLCFACILITY NUMBER:
392701090
ADMINISTRATOR:ONGA, SHERONFACILITY TYPE:
735
ADDRESS:2112 WALL STTELEPHONE:
(209) 362-6871
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 0DATE:
10/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Cheryl Magsayo and Sheron OnggaTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) Albert Johnson arrived announced for a pre-licensing inspection. There are no residents in care as facility license is pending.

LPA toured the interior and exterior of the facility including the common areas, bathrooms, residents room and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. . LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been serviced.

LPA observed a complete first aid kit. Land telephone service number is to be active today. LPA observed locked cabinet where resident files and medications will be stored. LPA measured hot water at 111.5*F in a resident bathroom and the inside temperature measured 76*F.

LPA observed books, puzzles and games on site. LPA observed (1) unlocked gates and a ramp on the side of walk way.

Based on today's inspection, the pre-licensing is completed /passed. LPA completed the COMP III. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. CAB will be notified accordingly.

Exit Interview and copy of report provided
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1