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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000023
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:25:43 PM

Document Has Been Signed on 05/17/2024 03:25 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:ROBEL CARE HOMEFACILITY NUMBER:
397000023
ADMINISTRATOR/
DIRECTOR:		PIL, INGRIDFACILITY TYPE:
735
ADDRESS:3841 OTTO DRIVETELEPHONE:
(209) 688-3149
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Mariano Pil TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management inspection regarding two (2) residents placed in the facility on respite care. LPA explained purpose of visit to the staff.

LPA Lewis took a tour of the facility. LPA observed medication in a locked to residents in care. LPA observed the residents beds were observed to be clean and sanitary. Main area for resident use was toured and the furniture intended for resident use was observed to be in good repair at this time. LPA observed food supply including ready made meals, microwavable items and snacks to be sufficient to meet the residents needs at this time. LPA also interviewed staff on duty. LPA observed residents were sleeping in their rooms. The residents were observed to be in overall good health. LPA informed the staff to update the Regional Office of any changes.

Per California Code of Regulations, Title 22 no deficiencies were observed during today's case management inspection. The matter is still under investigation.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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