Community Care Licensing

Document Has Been Signed on 08/26/2021 10:51 AM - It Cannot Be Edited

FACILITY NAME:	WILLOW CARE HOME		FACILITY NUMBER:	397000569
ADMINISTRATOR:	QUIAOT, KATHLEEN		FACILITY TYPE:	735
ADDRESS:	1633 WILLOW PARK WAY		TELEPHONE:	(209) 462-2923
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Mercedes Rigor		TIME COMPLETED:	11:00 AM

NARRATIVE

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LPA Johnson arrived unannounced to clear the POC's from visit dated 08/05/2021. The following deficiencies, initially cited during a visit on 08/05/2021, have been cleared: Section Cited: 80020(a) Date Due: 08/06/2021 Plan of Correction: Administrator replaced the fire extinguisher today. A civil penalty is hereby assessed on today's date in the amount of $500. Corrections: Cleared By Visit Clearance Date: 08/26/2021 Section Cited: 80068.2 Date Due: 08/19/2021 Plan of Correction: The Administrator will update R1 thru R6's service plan and updated them as required. Proof of this will be submitted to licensing by 8/19/2021. Corrections: Cleared By Visit Clearance Date: 08/26/2021

SUPERVISORS NAME: Stephenie Doub LICENSING EVALUATOR NAME: Albert Johnson LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021