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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:41:29 PM

Document Has Been Signed on 02/23/2023 03:41 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
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:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Maricor JusonTIME COMPLETED:
02:30 PM
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On 2--23-23 at 1:15pm, Licensing Program Analyst (LPA) Michael Bilger conducted unannounced 1 Year Required Annual Inspection visit. LPA met with the Administrator Maricor Juson and explained the purpose of the visit. Administrator Certificate expires 3/24/2023.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. Facility is a 2 story home with all client bedrooms upstairs. All clients are ambulatory. There is a dining nook off the kitchen area. There are 4 bedrooms, all shared, and 3 bathrooms. There is 1 bathroom downstairs.
The facility submitted a LIC 808 mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors as needed. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 105*F and 120*F in the bathroom and room temperature reads 70*F . LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers last updated 2/1/23. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Administrator. A copy of reports and appeal rights left at facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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