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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701393
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:15:35 PM

Document Has Been Signed on 07/18/2024 04:15 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:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Administrator Emilia BaguinonTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 07/18/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility announced to complete a pre-licensing visit. LPA Campbell met Administrator Emilia Baguinon to explain the purpose of the visit. The Administrator's license was observed with certificate #6031570735 with expiration date 2/16/25. The facility will serve adults between the ages of 18 and 59.

Upon entry, LPA Campbell observed no clients in the residence. An active functioning phone was standing on the kitchen counter. Administrator Baguinon lead LPA Campbell to the patio door where patio furniture stood outside with an umbrella providing shade and the required base needed to keep it standing. The path to the fire exit leading to the street was clear and without obstructions. A shed near the exit was locked to make sure its contents were inaccessible to the residents.

During the prior visit, room #3 would house two clients and room #1 would have only one client. The administrator has now re-arranged the bedrooms so that room #1 has two beds and room #3 has one bed. This will allow two clients to have enough room in #1 to have all the required furniture for two (2 x chairs, 2 x night stands, etc.).

The administrator then identified the lock that had been added to the laundry room. Detergent and other cleaning products could now be stored on shelves over the washer and dryer without allowing access to residents. All deficiencies were resolved.
There were no other deficiencies observed during the course of this Pre-licensing visit.
Comp III was reviewed with applicant.
Exit Interview was conducted and a copy of this report was provided to the applicant at the end of the visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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