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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701090
Report Date: 04/03/2023
Date Signed: 04/04/2023 09:16:07 AM

Document Has Been Signed on 04/04/2023 09:16 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
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: 2DATE:
04/03/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Xsavior IrvinTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced for a post licensing visit. There are two residents in care. The facility has completed it's vendorization with VMRC.

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 following posted in the facility: See Something Say Something complaint poster, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been serviced. The facility has had two incidents with residents being sent out to mental health. R1 and R2 were released from Mental health. R1 moved back with family; she was on respite and R2 is back with the facility. LPA was able to review the incident reports.

No deficiencies are cited during today's inspection.

Exit interview and copy of report provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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