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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790073
Report Date: 02/11/2022
Date Signed: 02/15/2022 05:54:39 AM

Document Has Been Signed on 02/15/2022 05:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MARTIN'S CIRCLEFACILITY NUMBER:
392790073
ADMINISTRATOR:MARTIN, KENNETHFACILITY TYPE:
735
ADDRESS:1735 LARAMIE WAYTELEPHONE:
(209) 482-7409
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 3DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Aryanna RhoddTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual inspection on this date. The Administrator for the facility, Kenneth Martin was informed of the purpose of the visit by phone and he gave directions to have care staff assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility is Regional Center vendorized home with 3 clients and 3 bedrooms. All clients were at the home and engaged in activities.

LPA toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Smoke alarms were tested and were operable. Fire extinguishers were serviced in April 2021. Toxins and medications were locked and inaccessible to clients in care. Food supply determined to be adequate. Inside and outdoor exits were unlocked and accessible. Water temperature was measured at 111.5 degrees F.

LPA observed the following posted in the facility: COVID requirements, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MARTIN'S CIRCLE
FACILITY NUMBER: 392790073
VISIT DATE: 02/11/2022
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FAcility has a pool in the back yard enclosed by a 5 foot fence with a locked gate. Kenneth Martin Administrator Certification #6043857735 Expires 6/29/22.

Exit interview held with acting Administrator, no deficiencies were identified or cited on this inspection. LPA issued and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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