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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000457
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:53:46 PM

Document Has Been Signed on 01/15/2025 12:53 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: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:
01/15/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Shalimar GouldingTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 1-15-25 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding a health and safety follow up for resident1 (R1). LPA met with Administrator Shalimar Goulding and explained the purpose of the visit. During today's case management. LPA conducted a brief interview with R1. Based on interview, it was determined that R1 moved to facility on 9-5-24 after R1's previous residence closed. Additionally based on interview, R1 has adjusted to new environment including personal preferences fulfilled. LPA observed R1's personal belongings and medications in place. LPA observed R1 to be adjusting to new routine within environment.

As a result of today's case management, no citations are issued. An exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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