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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701250
Report Date: 03/27/2024
Date Signed: 03/27/2024 10:09:52 AM


Document Has Been Signed on 03/27/2024 10:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Maxima Martin TIME COMPLETED:
10:15 AM
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On 03/27/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Maxima Martin and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six non-ambulatory residents, which one may be bedridden. The facility has an approve hospice wavier for 6.

The LPA Martinez toured the facility with Maxima Martin on 03/27/2024 at 9:30 AM.

The facility temperature measured at 72 degrees, and water temperature measured at 105 degrees. The facility was sanitary and furnished with no foul odors. The resident bedrooms and bathrooms were sanitary and furnished. The facility has an area for activities, and has a public telephone. The facility had an adequate food supply, and the kitchen was sanitary. The facility fire extinguisher, smoke detectors, and carbon detectors were in good repair. The fire emergency gate was in good repair. The exterior of the home was clear of debris. LPA Martinez conducted a facility file review, and files were maintained.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. There were no deficiencies cited at this time, and exit interview was conducted. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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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