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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701252
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:23:43 AM


Document Has Been Signed on 03/28/2024 10:23 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 1FACILITY NUMBER:
392701252
ADMINISTRATOR:MARTIN, MAXIMAFACILITY TYPE:
740
ADDRESS:3519 NOVARA WAYTELEPHONE:
(510) 366-6585
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 5DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Maxima Martin TIME COMPLETED:
10:30 AM
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On 03/28/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection at 9:27 AM. 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 can be bedridden The facility has a hospice waiver for 6 residents. There are currently five residents who reside at this facility.

The LPA Martinez toured the facility with Maxima Martin on 03/28/2024 at 10:00 AM.

LPA Martinez conducted a file review, and all files were maintained. The facility fire extinguishers are in good repair. The exterior fire emergency gate is in good repair. The facility has an adequate food supply, and the kitchen was sanitary and furnished. The resident bedrooms are furnished and sanitary. The laundry room and bathrooms are furnished and sanitary.

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.


An exit interview was conducted, and a copy of this report was given to the facility at the end of the visit.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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