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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701216
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:47:14 PM

Document Has Been Signed on 03/04/2024 12:47 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LINCOLN ROAD CARE HOMEFACILITY NUMBER:
392701216
ADMINISTRATOR:ASUNCION, TROPYFACILITY TYPE:
735
ADDRESS:120 E LINCOLN ROADTELEPHONE:
(209) 915-1713
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Wendell And LimuelTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 3/4/2024. The LPA met with Staff.

The facility is an adult residential facility funded by Valley Mountain Regional Center with a current census of 6. Facility has 4 bedrooms and 3 bathrooms. Three bedrooms are for resident use. Facility has a formal dining area and a formal living room. LPA conducted the inspection using the CARE tool.

LPA and Staff inspected the physical plant at approximately 10:05am to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor and clean. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed four (4) client files and two (2) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs at 10:20am. LPA reviewed resident and staff files, and interviewed both. All staff were cleared and associated to the facility. First aid kit was checked and is complete. No citations given.

Exit interview conducted. A copy of this report was left with the Staff.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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