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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701465
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:57:03 PM

Document Has Been Signed on 01/17/2025 03:57 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:STAR BLOOM CARE HOME 2 INCFACILITY NUMBER:
392701465
ADMINISTRATOR/
DIRECTOR:		ACUAVERA, ARLENEFACILITY TYPE:
735
ADDRESS:44 SCOOTER WAYTELEPHONE:
(209) 623-8730
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 0DATE:
01/17/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:ACUAVERA, ARLENETIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/17/2025, Licensing Program Analyst (LPA) Kesha Lewis arrived announced to conduct a Pre-Licensing visit. LPA was greeted by applicants, 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 4 residents, of which 4 may be non-ambulatory.

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. A review of food supply was conducted to ensure a 2 day perishable and 7 day non-perishable food supply was available. This facility will have a locked medication cabinet located in entrance hallway. A first aid kit was observed and had all the required components. Fire extinguisher was located in kitchen and was serviced on 09/05/2024 by the local fire company.
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. in the laundry room 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.
Hot water temperature was taken to ensure that it was in within 105-120 degrees.
No bodies of water were observed.

Comp III completed and copy of the report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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