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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000569
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:06:28 PM

Document Has Been Signed on 08/14/2024 03:06 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:WILLOW CARE HOMEFACILITY NUMBER:
397000569
ADMINISTRATOR/
DIRECTOR:		QUIAOT, KATHLEENFACILITY TYPE:
735
ADDRESS:1633 WILLOW PARK WAYTELEPHONE:
(209) 462-2923
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 3DATE:
08/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Bernadette PuaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 08/14/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with staff and spoke with administrator on the phone and explained the purpose of the visit.

LPA reviewed

1. Administrator presence with no less than 40 hours per week by 5-21-24.
2. Licensee will create a plan on how items brought into the facility will be inventoried and stored this plan will be sent to the department by 5/21/2024.
3. Licensee will provide training on personal rights, eviction procedures, reporting requirements, needs and services plans and care and supervision. These training's are due to the department within 30 days of this meeting and are to be completed every 6 months for a total of 3 training's in the next twelve (12) months.
4. Participation in the Technical Support Program.

Based on records reviewed all training's have been completed and will be re-done in six (6) months with the same outside vendor. The administrator is present 40 hours a week based on the LIC 500 Provided and licensee has been registered with TSP waiting for further contact. There is a written plan on how items brought into the facility will be inventoried and stored.

Exit interview conducted. Copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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