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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701278
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:34:47 PM


Document Has Been Signed on 07/27/2023 03:34 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, JAGTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE RDTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 12DATE:
07/27/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jagtar SinghTIME COMPLETED:
03:45 PM
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On 7/27/23 at approximately 11:55am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation. During the course of the visit, LPA Jensen met with Licensee Jagtar Singh who requested some technical assistance as this is a newly licensed facility..

LPA Jensen provided technical assistance in the following areas:

Reporting Requirements
Personal Rights
Changes in condition

No citations were issued as a result of this case management. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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