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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701090
Report Date: 10/11/2022
Date Signed: 10/11/2022 06:03:17 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/11/2022 06:03 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:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Norma OTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived Unannounced for a case management inspection. There are no residents in care. The facility is waiting for VMRC to complete vendorization.

The facility license was for 4 ambulatory residents. The Licensee initiated a change to the license to now read as 4 non- ambulatory residents.

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.

The fire marshal has cleared the facility to accommodate 4 non- ambulatory residents.

Exit interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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