<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701244
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:18:31 PM

Document Has Been Signed on 11/15/2023 12:18 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:OGDEN CARE HOMEFACILITY NUMBER:
392701244
ADMINISTRATOR:TAN, AARON ANTHONYFACILITY TYPE:
735
ADDRESS:3053 OGDEN LANETELEPHONE:
(209) 298-7171
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 3DATE:
11/15/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cloe TanTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/15/23 at approximately 9:50am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility announced to conduct an post licensing inspection visit. LPA met with the administrator Aaron Tan and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 3 bedrooms and 2.5 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 3 ambulatory residents.

Facility Observation: Upon entry 2 residents were engaged with staff at the dining table, one resident was at day program. During the visit clients had lunch together at the dining table. Lunch was Peanut butter and jelly sandwiches, fruit (bananas), cookies and milk or juice.

LPA completed 1 resident interviews and 1 staff interviews. During this inspection 3 of 3 resident files and 3 of 13 staffing files were reviewed for regulatory compliance.
Staff files contained required contents including staff training requirements.
Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

Water temperature in common bathroom reads 113.5*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 69*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
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OGDEN CARE HOME
FACILITY NUMBER: 392701244
VISIT DATE: 11/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility’s liability insurance is current and up to date per regulatory requirements. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts monthly fire drills.

LPA requested and received an updated copy of LIC 308 and LIC 500 and Surety Bond.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Aaron Tan.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2