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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:28:17 PM

Document Has Been Signed on 03/07/2024 03:28 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:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 3DATE:
03/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sherry Camero, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst Renee Campbell arrived to facility at approximately 2:30 pm unannounced with Licensing Program Manager Lisa Rios. Upon entry, LPA Campbell was greeted by R1 and R2 and S1.

The bedroom contained a fall bed, chest, television, and nightstand. Clients store their clothes in the mirrored closet next to the bathroom. R1 was observed preparing food, R2 was standing in the bedroom entrance and R3 was in the bathroom showring.

LPA Cambell observed a one-bedroom suite. There was enough room for two residents to sleep in the bed, one resident to sleep on the couch that pulls out at night, and one staff person to sleep on a cot provided by the hotel. The common areas were observed to be clean and odor free. A grey couch was in the dining room with a kitchenette. A four-chair dining table was set against the wall. A bowl of candy and snacks for residents was observed on the table and a coffee table with a lamp was beside the couch. Staff used a curved table with a desk lamp to complete paperwork. Resident medication and knives were locked in a facility lockbox and inaccessible to residents. Per S1, the supply of food is refreshed weekly, and LPA Campbell observed enough perishable foods to last three days and enough non-perishable foods to last approximately one week.

The department will continue to monitor the situation with health and safety checks until the residents are able to return to primary residence. No deficiencies cited during this visit. An exit interview was conducted with Administrator, Sherry Camero and a copy of this report was left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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