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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 02/09/2024
Date Signed: 02/09/2024 07:44:34 PM

Document Has Been Signed on 02/09/2024 07:44 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:
02/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
06:50 PM
MET WITH:Sherry Mel CameroTIME COMPLETED:
07:50 PM
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On 2/9/24, at 6:50pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to 3240 W. March Lane conduct a health and safety visit. LPA met with staff on duty, Sherry Mel Camerro and explained the purpose of the visit. Currently, the facility is undergoing repair. As a result, some of the residents in care have been relocated temporarily to a hotel at this time.

Current census was 3 as one resident had temporarily relocated to another facility owned by the same licensee. During this visit, Sherry was orienting the next shift staff on what to do for the night. LPA observed staff brought in a cot bed for the staff to use. At this time of the visit it was observed that all residents have their own bed. Two residents have their own room with their own bed. One resident sleeps in the living room area with own pull out bed. The room has two bathrooms for resident use. Additionally, the room has a kitchenette equipped with electric range for cooking, microwave, refrigerator and dinning table. The room is also stocked with utensils and cooking supplies such as pots and pans. Each resident have their own TV for entertainment. LPA observed another staff brought in food supplies and drinks for residents.

A brief interview with Sherry was conducted regarding food and planned activities. Per Sherry, they plan to go outing tomorrow. Per Sherry, there will be at least one staff in the room with the residents at all time for supervision. The hotel provided safety lock boxes for the residents' medication located at the front desk of the hotel. LPA conducted interview with residents and informed LPA that they are good.

The department will continue to monitor the situations with health and safety checks until the residents are able to return to their primary residence.

Based on observations during this visit, there are no deficiencies cited during this visit. An exit interview was conducted Sherry and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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