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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 10/15/2021
Date Signed: 10/15/2021 02:01:52 PM

Document Has Been Signed on 10/15/2021 02:01 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MELMAR'S GUEST HOME #3FACILITY NUMBER:
397001192
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:5465 GOVERNOR CIRCLETELEPHONE:
(209) 323-4193
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
10/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:n/aTIME COMPLETED:
02:00 PM
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On 10-15-21 at 1:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a continued case management visit for a previous case management visit on 10-1-21. Upon arrival, LPA rang door bell and knocked. LPA observed through front door window that lights were off and shades were drawn. After 5 minutes there was no answer. LPA attempted to contact Administrator Maricor Camero via phone but unsuccessful as no voicemail option was available. LPA sent email to Administrator informing her of LPA's arrival and a request to call LPA. At 2:00pm, LPA did not receive a response from Administrator and another email was sent to Administrator informing her that LPA will return at a later time.

LPA was unable to complete case management visit and will return a later date for completion. Administrator unable to sign document due to not being present. No deficiencies cited.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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