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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 03/17/2023
Date Signed: 03/19/2023 09:21:58 PM

Document Has Been Signed on 03/19/2023 09:21 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:
03/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Maricor JusonTIME COMPLETED:
12:15 PM
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Licensing Program Analyst Albert Johnson arrived to conduct an unannounced case management visit. LPA met with staff and informed them that the reason for this case management visit is to make the facility aware of the fact that there is a eviction procedure that must be followed.

LPA Johnson made contact with the Administrator/Licensee this morning to inform the facility that R1 will be illegally evicted if R1 is not given an approved by the department 3 day notice or a 30 day notice.

R1 was aggressive toward another resident on 3/13/23 and injured the licensee, however, there was no police involvement on this matter and the facility did not submit a REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE SOC341 to the Department or Regional center.

The facility will submit a 3 day and a 30 day notice for R1. No deficiencies were not issued today.

Exit interview. Copy of report provided to facility representative.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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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