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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 10/19/2021
Date Signed: 10/19/2021 05:05:55 PM

Document Has Been Signed on 10/19/2021 05:05 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:
10/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Ilbefonso LetranTIME COMPLETED:
05:05 PM
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On 10/19/21 at 3:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 10-4-21 involving Resident1 (R1) found with bed bugs on shirt and backpack while at a day program. LPA met with Administrator Ilbefonso Letran and explained the purpose of the visit.

LPA conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. All sharp objects and toxins were secured and inaccessible to clients in care. Room temperature was adequate during today’s visit. There are no obstructions to fire exits inside or outside facility. There was 1 staff on duty during visit. LPA reviewed incident report with Administrator and requested records of on-going pest control services as well as facility’s plan for preventing bed bugs in facility. LPA also interviewed Administrator. Based on the interviews conducted and records reviewed it is determined that pest control services for bedbugs has been on-going since March of 2021. LPA also observed service invoices for services performed. LPA conducted an inspection of facility common areas and resident bedrooms and did not find evidence or observation of bedbugs.

Based on the interviews, inspection, and additional documentation received, the department has closed this case management and no further investigation is required.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #3
FACILITY NUMBER: 397001192
VISIT DATE: 10/19/2021
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Per California Code of Regulations, Title 22 there were no deficiencies observed or cited during today's case management inspection.
An exit interview was conducted with Ilbefonso Letran and a copy of this report was left with Ilbefonso.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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