<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701374
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:33:29 PM

Document Has Been Signed on 03/19/2025 03:33 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 HOME INCFACILITY NUMBER:
392701374
ADMINISTRATOR/
DIRECTOR:		SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE ROADTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 15CENSUS: 8DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Jagtar SinghTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3-19-2025 at 10:08am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Jagtar Singh and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 8. Facility has 6 bedrooms and 3 bathrooms for resident use. A separate cottage on the property is not in service at this time. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 76*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 6-7-24. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 resident files and 3 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 3 resident interviews and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CHEROKEE RETIREMENT HOME INC
FACILITY NUMBER: 392701374
VISIT DATE: 03/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility’s liability insurance is up to date. Facility does not contain any bodies of water. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Administrator departed facility for other pre-arranged commitments and gave permission for caregiver (S1) to sign in his absence. Exit interview was held and a report was given to S1.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2