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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701345
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:22:55 PM

Document Has Been Signed on 04/03/2024 01:22 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:ALINE & ADRIANNE'S HOUSE IFACILITY NUMBER:
392701345
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		GENEEN, BLANDFACILITY TYPE:
735
ADDRESS:3403 BELLEVIEW AVE.TELEPHONE:
(209) 910-6482
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 3CENSUS: 0DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:GENEEN, BLANDTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 04/3/2024, Licensing Program Analyst (LPA) Kesha Lewis arrived announced to conduct a Pre-Licensing visit. LPA was greeted by applicants, GENEEN, BLAND and explained the purpose of the visit.
The purpose of this visit was to conduct a Pre-Licensing Visit.
This facility will be licensed to hold 3 residents, of which 3 may be ambulatory in bedrooms #1, #2 and #3. This facility is also awaiting vendorization from Valley Mountain Regional Center and will accept and hold Level 3 residents.

A tour of the facility was conducted. Smoke detectors and carbon monoxide detectors were tested and are in good repair.

A tour of the kitchen area was toured. This facility will have a locked medication cabinet located in the hallway. A first aid kit was observed and had all the required components. Fire extinguisher was located in kitchen and was purchased on 09/26/2023 at home depot.
A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair.
A tour of the backyard was conducted with no hazards present. Perimeter gate was observed to be in good repair.
A tour of garage was conducted. A washer and dryer was identified. Detergent, toxins and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the resident bedrooms were conducted. Furniture and furnishing were observed to meet the residents needs.
A linen closet was located in hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time.
A tour of three resident restrooms were completed. Hot water temperature was taken to ensure that it was in within 105-120 degrees. Comp III completed.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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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