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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000457
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:55:53 AM

Document Has Been Signed on 10/03/2024 11:55 AM - 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:JAVIER'S GUEST HOMEFACILITY NUMBER:
397000457
ADMINISTRATOR/
DIRECTOR:		ESTHER JAVIERFACILITY TYPE:
735
ADDRESS:8127 BURGUNDY DRIVETELEPHONE:
(209) 475-1299
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Shalimar GouldingTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 10/3/2024 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. The purpose of today's case management is to follow up on a resident who was previously admitted from another licensed facility. LPA met with Administrator Shalimar Goulding and explained the purpose of the visit. LPA conducted brief interview with Administrator and resident1 (R1). It was determined that R1 moved into facility on 9/5/2024. LPA observed all personal belongings of R1 in place as well as medications. It was determined through interview that R1 is not currently experiencing distress or anxiety.

LPA conducted facility tour including common areas, resident bedrooms, bathrooms, kitchen area and outside of facility. LPA observed facility to be clean and sanitary with no foul odors noted. LPA observed facility to have sufficient food supply. Water temperature reads between 105-120*F. Facility temperature is 80*F. No obstructions to fire exits noted.

No citations issued today. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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