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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701418
Report Date: 08/22/2024
Date Signed: 08/26/2024 11:59:02 AM

Document Has Been Signed on 08/26/2024 11:59 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:BLAKE RESIDENTIALFACILITY NUMBER:
392701418
ADMINISTRATOR/
DIRECTOR:		BLAKE, MIERRAFACILITY TYPE:
735
ADDRESS:9549 TWIN BROOKS LANETELEPHONE:
(209) 905-6773
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 6CENSUS: 0DATE:
08/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:M. BlakeTIME VISIT/
INSPECTION COMPLETED:
12:33 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived announced to complete a pre licensing inspection. LPA met with M. Blake.

Currently there are no clients at the facility. Fire clearance was granted on 6/18/2024 for 5 (five)-ambulatory clients and 1(one)- non-ambulatory client to be housed in room 2 only. Facility was inspected both indoors and outdoors. LPA inspected proposed bedrooms, bathrooms, kitchen, garage, and common areas. Outdoor exits are clear and accessible. There are two floors to this facility. 5 resident bedrooms, and 3 bathrooms were observed. There is a jacuzzi in the backyard with a locked cover. The jacuzzi has been drained and it not in use.

Hot water temperature was measured at 120 degrees.(Advisory given to check water prior to first resident moving in). Smoke detectors and carbon monoxide detectors were checked and operational. Fire extinguisher indicator revealed a full charge. Kitchen is clean sanitary, and in good repair. There will be a locked areas for cleaning supplies, sharps, medications and toxins.

Component III was completed. The land line is (209) 323-4657

The applicant has passed the pre-licensing inspection.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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