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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000569
Report Date: 01/28/2023
Date Signed: 02/01/2023 09:46:01 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/01/2023 09:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WILLOW CARE HOMEFACILITY NUMBER:
397000569
ADMINISTRATOR:QUIAOT, KATHLEENFACILITY TYPE:
735
ADDRESS:1633 WILLOW PARK WAYTELEPHONE:
(209) 462-2923
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 2DATE:
01/28/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Mercedes RigorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with Mercedes Rigor explained the purpose of the visit. LPA was later joined by Kathleen Quiaot.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 110 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers, Smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 2 resident and 1 staff files, including criminal record clearances.

Fire drill was completed on 12/2022. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

No deficiencies were cited

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2023
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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