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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000457
Report Date: 01/18/2022
Date Signed: 01/18/2022 12:32:40 PM

Document Has Been Signed on 01/18/2022 12:32 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:JAVIER'S GUEST HOMEFACILITY NUMBER:
397000457
ADMINISTRATOR:ESTHER JAVIERFACILITY TYPE:
735
ADDRESS:8127 BURGUNDY DRIVETELEPHONE:
(209) 475-1299
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
01/18/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Shalimar GouldingTIME COMPLETED:
11:35 AM
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On 1-18-22 at 10:49am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a quarterly health and safety check. LPA met with Administrator, Shalimer Goulding and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 6 residents. Facility is approved for 2 non-ambulatory.

The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. The temperature inside the facility was measured at 73*F within the required range of 68*F and 85*F. Water temperature in bathroom measured 118.4*F. COVID signage was posted throughout facility. There is a single point entry for COVID screening. LPA was screened upon entry. Smoke detectors and carbon monoxide detectors were functioning properly. Fire extinguisher was last check 4/5/21. LPA observed resident rooms and common areas to be clean and sanitary during visit. Facility has an approved COVID mitigation plan in place.

LPA observed food supplies of 7 days of nonperishable foods and 2 days of perishable foods on site. Menu included appropriate food to meet nutritional guidelines. Today's staffing included 1 caregiver during the day, afternoon and night shift. No foul odors noted. No obstructions to fire exits noted.

As a result of today’s visit, no deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview conducted with Shalimer Goulding and a copy of report given to Shalimer..
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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