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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392701183
Report Date:
09/21/2023
Date Signed:
09/21/2023 10:01:34 AM
Document Has Been Signed on
09/21/2023 10:01 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:
STAR BLOOM CAREHOME
FACILITY NUMBER:
392701183
ADMINISTRATOR:
ACUAVERA, ARLENE
FACILITY TYPE:
735
ADDRESS:
2410 LAGUNA CT
TELEPHONE:
(209) 641-9320
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95206
CAPACITY:
6
CENSUS:
DATE:
09/21/2023
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
09:59 AM
MET WITH:
TIME COMPLETED:
10:00 AM
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See annual 9/21/23
SUPERVISORS NAME
:
Stephenie Doub
LICENSING EVALUATOR NAME
:
Albert Johnson
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
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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