392701318-10-5-2023-27-AS-AMAZ-CWBNGB-20231005102653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701318
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:27:02 AM

Document Has Been Signed on 10/05/2023 10:27 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:	ESTEEMED RESIDENTIAL CARE 2		FACILITY NUMBER:	392701318
ADMINISTRATOR:	WALTERS, CHRISTOPHER		FACILITY TYPE:	735
ADDRESS:	2431 ETCHEVERRY DRIVE		TELEPHONE:	(925) 219-2787
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY: 4		CENSUS: 0	DATE:	10/05/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Christopher Walter and Imani Warren.		TIME COMPLETED:	10:35 AM

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Licensing Program Analyst (LPA) Avelina Martinez arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez met with Christopher Walter and Imani Warren, whom assisted LPA Martinez in today’s inspection.

Facility has a fire clearance for 4 ambulatory clients and 0 non-ambulatory clients. Administrator, Christopher Walter, will be the Administrator of this facility. The facility administrator’s certificate is current and expires on November 28, 2023. The Administrator has sent their renewal application to the Department.

LPA Martinez inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. LPA Martinez toured the facility with Christopher Walter and Imani Warren.

Food Services: The facility has an adequate food supply, and has an emergency water and food kit. In addition, the kitchen skin water temperature measured at 105 degrees. The facility also has locked cabinets for sharp objects and toxins are locked in a cabinet. The refrigerator and freezer are in good repair. The facility has a menu.

Care & Supervision: This facility is in the process of being vendorized by Valley Mountain Regional Center. The facility will be a level 4I, and the facility will have a behaviorist and a physician that will visit the facility. The facility will have awake staff which will consist of the following: 2 AM staff; 3 PM staff, 1 Noc staff. This schedule will be dependent on clients needs and may change.

Records Review: The facility has client, employee files. In addition, the facility has the required postings through out the facility.

Medication: The facility has will be using medication administration record (MAR) and each resident will have their own medication box. The facility has a first aid kit and a manual.

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SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESTEEMED RESIDENTIAL CARE 2	FACILITY NUMBER: 392701318
	VISIT DATE: 10/05/2023

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Emergency Plan & Natural Disaster Plan & Infection Control Plan: The facility fire extinguisher tags were inspected, and the last fire inspection was on June 01, 2023. Carbon detectors and smoke detectors were inspected and are in good repair. Fire drills will be conducted monthly, and the facility exterior emergency exit doors are in good repair. The facility also has an infection control plan.

Exterior Of The Facility: The facility front yard is clear of debris, and the front door is level to the ground. The back yard patio is covered, and has an area for client use. The back yard is clear of debris and has clear pathways for client usage. The facility does not have any large bodies of water.

Interior Of the Facility: Facility bedrooms, bathrooms, and laundry room are furnished and are in good repair. The facility has a public telephone, and has area for activities.

The applicant has passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing visit has been completed. Furthermore, Administrator, Christopher Walter, has completed component 3 in July of 2023 at Walter's Residential Care 4. As a result, LPA Martinez waived Component 3. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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