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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701185
Report Date: 02/01/2023
Date Signed: 02/01/2023 03:23:40 PM

Document Has Been Signed on 02/01/2023 03:23 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:COOKS CARE RESIDENTIAL FACILITY #2FACILITY NUMBER:
392701185
ADMINISTRATOR:COOKS, MICHAELFACILITY TYPE:
735
ADDRESS:2419 CLARIDGE LNTELEPHONE:
(209) 817-4860
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 0DATE:
02/01/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Nicole TaylorTIME COMPLETED:
03:40 PM
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On 2/1/23 at 2:15pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a 90-day post licensing inspection visit. LPA was greeted by facility house manager Nicole Taylor and LPA explained the purposes of the visit. Administrator Michael Cooks was notified of LPA's visit and explained the purpose of the visit.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 4-bed adult residential facility with a current census of 0. Facility is currently awaiting regional center approval. LPA was screened upon entry for temperature and asked to sign in. Facility has 4 bedrooms and 2 bathrooms for resident use. All knives, toxins, and other chemicals were locked and secured.. Resident rights posted. Facility sketch updated. Administrator certificate posted and expires 3-3-23.
The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and backyard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F.
Water temperature reads 105*F and 120*F in the bathroom and room temperature reads 71*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguisher was fully charged and dated 7-15-22. Emergency disaster plan updated.
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Nicole Taylor
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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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