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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701393
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:50:15 PM

Document Has Been Signed on 07/09/2024 03:50 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:RESIDENCE, THEFACILITY NUMBER:
392701393
ADMINISTRATOR/
DIRECTOR:		BAGUINON, EMILIAFACILITY TYPE:
735
ADDRESS:4960 MOORCROFT CIRCLETELEPHONE:
(209) 670-6088
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 0DATE:
07/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Emilia Baguinon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 07/09/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct an announced pre-licensing inspection. LPA Campbell met Administrator Emilia Baguinon and explained the purpose of the visit. The applicant holds an administrator license #6031570735 and it expires on 02/16/2025. They are seekling licensure for a four bed ARF. Fire Clearance was provided for (1) non-ambulatory resident in Room #3.

The facility is located in a single floor residence with 4 bedrooms and 2 bathrooms. LPA Campbell inspected the common living room area, dining rooms, bedrooms, bathrooms, laundry room, backyard and kitchen. Currently, there are no clients in residence. The smoke alarm and carbon monoxide alarm were verified as functioning. The refrigerator and freezer temperature were within the required temperature ranges. Sharps were observed to be locked with a key in a kitchen drawer. Records, first aid kit and medicine containers were locked in a supply closet near the kitchen. Any keys will remain with the administrator or staff on duty.

When the first aid kit was observed, no thermometer was found. During an inspection of the backyard, a large planter was observed tipped over with dirt spilling out of it and presented an obstruction in the path to the fire/street exit. An unlocked shed near the fire exit contained a mower with planters and sticks of wood. A collapsed umbrella lay on the living room sofa for future installation outside with the patio furniture

Per the administrator, the laundry room will be locked to prevent access to the washer, dryer and garage. Of the three bedrooms, one of them will be shared by two residents. Due to it's size, there is not enough room for each resident to have their own chair, night stand, lamp and chest of drawers. After consultation with LPA Campbell, administrator has agreed that the residents can share the large chest with their own drawers. This will require additional furniture purchases for the residents. The required operating phone available to clients was connected and operating during today's visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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: RESIDENCE, THE
FACILITY NUMBER: 392701393
VISIT DATE: 07/09/2024
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Water in the bathroom was observed at 115 degrees Fahrenheit and within required measurements. At the time of inspection, the facility is not ready to be licensed LPA will schedule a visit to complete Component 3 and inspect the facility after they have made the following corrections.

1. Install locks on the laundry room.
2. Install locks on the outdoor shed.
3. Purchase a thermometer for the first aid kit.
4. Clean out the planter and dirt from the emergency path.
5. Purchase additional furniture for the shared room.
6. Purchase a base for the patio umbrella and install it outside with the patio furniture.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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