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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701278
Report Date: 02/06/2024
Date Signed: 02/06/2024 03:47:43 PM


Document Has Been Signed on 02/06/2024 03:47 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:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
392701278
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE RDTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 12DATE:
02/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jagtar SinghTIME COMPLETED:
02:15 PM
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On 2-6-24 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding exiting condition of facility's roof. LPA met with Administrator Jagtar Singh and explained the purpose of the visit. Administrator had to depart and authorized lead caregiver (S1) to sign in his absence. LPA conducted brief interview with Administrator and conducted facility observation. An additional observation was conducted on 1-25-24 as part of the investigation for complaint #27-AS-20240118123724. LPA observed roof to contain a heavy tarp on top for purposes of preventing leaks. Observation revealed there are no leaks at this time, however, roof is in need of repair. Interview revealed a plan is in place for future replacement of facility structure to include a new roof. Additional documentation revealed roof is in need of repair and a plan for new facility structure to commence by Summer 2024.

As a result of today's case management, there are no citations issued. Administrator made aware to continue to update regional office on status of the process of new construction. An exit interview was conducted with S1 and a copy of this report was provided to S1.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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