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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790073
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:47:35 PM

Document Has Been Signed on 12/21/2023 02:47 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:MARTIN'S CIRCLEFACILITY NUMBER:
392790073
ADMINISTRATOR:MARTIN, KENNETHFACILITY TYPE:
735
ADDRESS:1735 LARAMIE WAYTELEPHONE:
(209) 482-7409
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 4DATE:
12/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kenny Martin TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a case management Inspection Visit regarding an alert from Valley Mountain Regional Center. LPA was met by Staff member and Administrator joined 15 minutes later.

LPA toured kitchen and pantry in the house and also the food supply that was in the garage.


LPA'S observation of the food fresh fruit on table was oranges only, in the refrigerator it contained a small portion of lunch meat, chopped ham, cheese and tortillas and yogurt. Licensee add milk, bread, another pack of lunch meat and juice to the refrigerator.

The facility is not in compliance with Title 22 Regulation, the deficiencies can be found on the LIC 809-D pages


An exit interview was conducted with Kenny Martin and a copy of the LIC 809 reports, LIC 809-D pages and Appeals rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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
Document Has Been Signed on 12/21/2023 02:47 PM - It Cannot Be Edited


Created By: Kesha Lewis On 12/21/2023 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARTIN'S CIRCLE
FACILITY NUMBER: 392790073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/29/2023
Section Cited
CCR
85076(d)(1)

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(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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Licensee states he brings groceries most days and was shopping when LPA arrived. Licensee will send photos of food supplied and menu for the day through 12/31/2023.
kesha.lewis@dss.ca.gov

photos will be sent by 12/29/2023.
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Based on observation fresh fruit on table was limited only organges refridgratior had only yogurt and a small portion of lunch meat. which poses a potintial Health, Safety and, Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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