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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000457
Report Date: 11/08/2023
Date Signed: 11/08/2023 02:56:45 PM

Document Has Been Signed on 11/08/2023 02:56 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:
11/08/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shalimar GouldingTIME COMPLETED:
03:15 PM
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On 11-8-23 at 2:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a plan of correction (POC) visit. LPA met with Administrator Shalimar Goulding and explained the purpose of the visit.

On 10/23/23 the Licensee was cited for California Code of Regulations (CCR) 80087(a). A plan of correction was due as follows by 10/31/23: 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. During today's visit, Administrator produced a copy of proof of pest control agreement submitted to LPA on 10-27-23. During today's visit, LPA during verified email sent by Administrator to LPA on 10-27-23 containing pest control agreement.

No citations issued today. An exit interview was conducted with Shalimar Goulding and a copy of this report was reported to Shalimar.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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