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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701250
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:48:22 PM


Document Has Been Signed on 02/23/2023 03:48 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:YANNICA GUEST HOME 2FACILITY NUMBER:
392701250
ADMINISTRATOR:MARTIN, MAXIMAFACILITY TYPE:
740
ADDRESS:3956 NOVARA WAYTELEPHONE:
(510) 366-6585
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 0DATE:
02/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Maxima Martin, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an announced pre-licensing inspection and met with Maxima Martin, Licensee and Administrator on 02/23/23 at approximately 2;20 pm.

LPAs toured the clients bedrooms, bathrooms, dining rooms, common living areas, kitchen, and backyard. There is sufficient lighting around the facility. Client rooms are equipped with the proper furniture and lighting. Client's rooms have proper bedding and linens for the client's to use. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the clients.

All toxins and are locked away in the laundry room. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance as of 01/05/2023. Smoke detectors and Carbon Monoxide detector are equipped around the facility and were tested successfully. First aid kit is complete. Hot water temperature is measured at 107 degrees Fahrenheit. This facility has secure locked drawers for knives and other sharp objects. Facility has a hygiene/PPE, sign in area at the entrance for all visitors.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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