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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701118
Report Date: 05/01/2023
Date Signed: 05/01/2023 11:50:05 AM

Document Has Been Signed on 05/01/2023 11:50 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:WALTERS RESIDENTIAL HOME CARE 4FACILITY NUMBER:
392701118
ADMINISTRATOR:KOAYEN, TANNEHFACILITY TYPE:
735
ADDRESS:4011 OAK VALLEY RDTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 4CENSUS: 4DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Tanneh Koayen, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a Required - Annual visit on 05/01/2023 at approximately 8:45 am. Administrator Certificate expires for Tanneh Koayen on 07/09/2023.
LPA met with Tanneh Koayen and discussed the purpose of the visit. The facility is licensed for a capacity of 4 residents.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents who were engaged in their own respective activities during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 71 degrees, which is within the required range of 68-85*F. The hot water temperature was measured at 117 degrees Fahrenheit which is within the required range of 105-120*F.

LPA observed fire extinguisher(s) inspected on 04/10/2023, smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:

Personnel Report (LIC500)

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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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