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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701278
Report Date: 07/07/2023
Date Signed: 07/07/2023 04:03:52 PM


Document Has Been Signed on 07/07/2023 04:03 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:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
392701278
ADMINISTRATOR:SINGH, JAKTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE RDTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: DATE:
07/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jagtar SinghTIME COMPLETED:
04:15 PM
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LPAs Jensen and Fain arrived at the facility to continue a pre-licensing inspection. LPAs Jensen and Fain met with the current Licensee Rick Reed and applicant Jagtar Singh and explained the purpose of today's visit. This is a continuation of the pre-licensing visit conducted on 6/7/23 and does not necessarily address any items previously inspected.

LPAs Jensen toured the facility and grounds. The grounds have ample space for residents to engage in outdoor activities. There is outdoor furniture and various shaded areas for recreation. The facility consists of 2 structures. There is 1 main structure and an accessory dwelling unit that is referred to as the "cottage".
The cottage has 2 bedrooms and a bathroom. The washer and dryer are located in an outbuilding separate from the main house and cottage. All appliances were determined to be in working order.

The licensee has submitted an application for 15, 10 ambulatory residents and 5 non-ambulatory. There is a hospice waiver for 3. There are currently 13 residents of which 12 are ambulatory and 1 is non-ambulatory resident. The fire clearance has been corrected and accurately reflects that there are 2 structures on the premises used for housing residents.

LPAs Jensen and Fain engaged with several residents and all appeared to have their needs met. The facility maintains an adequate food supply. All medication, toxins and knives were observed to be locked and inaccessible to residents in care. Licensee will send liability insurance to LPA by email by 7/14/23.

Technical assistance was provided to the applicant in the areas of personnel and building and grounds.
The facility was determined to be in substantial compliance. A component III presentation was conducted.

The applicant has passed the pre-licensing inspection and copies of this report were given to the current licensee and applicant.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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