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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397000250
Report Date:
04/19/2024
Date Signed:
05/20/2024 02:22:47 PM
Document Has Been Signed on
05/20/2024 02:22 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 #2
FACILITY NUMBER:
397000250
ADMINISTRATOR/
DIRECTOR:
CAMERO, MARICOR
FACILITY TYPE:
735
ADDRESS:
6801 MONTAUBAN AVENUE
TELEPHONE:
(209) 683-6876
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95210
CAPACITY:
6
CENSUS:
DATE:
04/19/2024
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Kesha Lewis
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/19/2024
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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