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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000457
Report Date: 10/23/2023
Date Signed: 10/23/2023 12:10:53 PM

Document Has Been Signed on 10/23/2023 12:10 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:
10/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Shalimar GouldingTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10-23-23 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding presence of mice in facility. LPA met with Administrator Shalimar Goulding and explained the purpose of the visit. LPA reviewed incident report dated 10-12-23 and briefly interviewed Administrator. LPA also conducted facility observation. Based on incident report and interview, on 10-11-23, facility received a visit from county behavior health due to a caseworker reporting presence of a mouse. During this visit on 10-11-23, a mouse was witnessed in facility's garage, and brought to facility staff's attention. According to Administrator, facility is still in the process of securing a pest control company to service facility for mice, and general pest control. It was confirmed during today's visit that pest control is not currently in place. Facility observation did not reveal any presence of mice inside or outside facility on 10-23-23.

As a result of today's case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Shalimar Goulding and a copy of this report was provided to Shalimar. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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Document Has Been Signed on 10/23/2023 12:10 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/23/2023 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: JAVIER'S GUEST HOME
FACILITY NUMBER: 397000457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
80087(a)

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Building and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee will secure a pest control agreement to include rodent control. Licensee to submit a copy of pest control agreement to LPA by POC due date.

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Based on interview and record review, a mouse was observed in facility's garage. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023


LIC809 (FAS) - (06/04)
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