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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701118
Report Date: 07/26/2024
Date Signed: 07/26/2024 11:58:01 AM

Document Has Been Signed on 07/26/2024 11:58 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 4FACILITY NUMBER:
392701118
ADMINISTRATOR/
DIRECTOR:		KOAYEN, TANNEHFACILITY TYPE:
735
ADDRESS:4011 OAK VALLEY RDTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 4CENSUS: DATE:
07/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:KOAYEN, TANNEHTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management inspection regarding a new resident (R1) being transferred to the facility. LPA explained purpose of visit to the administrator.

The Department received an inquire regarding where a resident ( R1) was placed and if there were any placement concerns. The facility provided LPA with R1's pre- placement appraisal, and Behavior data, the behavior plan for R1 is being created and the facility is waiting for it to be delivered. LPA also interviewed administrator.

Per California Code of Regulations, Title 22 no deficiencies were observed and are being cited during today's case management inspection. The matter is still under investigation.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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