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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:32:46 AM

Document Has Been Signed on 12/06/2022 11:32 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:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 298-0652
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
12/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Maricor CameroTIME COMPLETED:
11:45 AM
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On 12-6-22 at 10:54am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding an incident reported on 11-24-22. LPA met with Administrator Maricor Camero and explained the purpose of the visit. LPA reviewed incident report with Administrator. Based on records review and interview with Administrator, it was determined that resident1 (R1) was experiencing minor shortness of breath on 11-22-22 and initially refused emergency services. It was further determined that after a brief conversation with R1's responsible party and administrator, R1 complied and was taken to the emergency room for evaluation and treatment within approximately 5 minutes. Currently, R1 is receiving care and supervision at a care home after being admitted from hospital.

Based on record reviews and interviews, it was determined that facility staff were able to meet R1's needs in a timely manner. No deficiencies cited as a result of today's case management. An exit interview was conducted with Maricon Camero and a copy of this report was provided to Maricon.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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