<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 07/21/2022
Date Signed: 07/22/2022 11:34:21 AM

Document Has Been Signed on 07/22/2022 11:34 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:MELMAR'S GUEST HOME #3FACILITY NUMBER:
397001192
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:5465 GOVERNOR CIRCLETELEPHONE:
(209) 475-8161
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ildefonso Letran, Assistant Administrator TIME COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) R. Campbell and LPA Michael Bilger conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Ildefonso Letran, Assistant Administrator .

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms of which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured between 105 and 120 degrees Fahrenheit. The fire extinguisher was last inspected on August 9, 2021 and all smoke alarms and carbon monoxide alarms were tested successfully. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

LPAs observed the following deficiencies:
- The sharps drawer in the kitchen was unlocked.
- Large amount of recyclables, extra doors and chairs need to be cleared from backyard.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 07/22/2022 11:34 AM - It Cannot Be Edited


Created By: Renee Campbell On 07/21/2022 at 12:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MELMAR'S GUEST HOME #3
FACILITY NUMBER: 397001192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited

1
2
3
4
5
6
7
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
8
9
10
11
12
13
14
This regulation was not met as evidenced by LPA observation during inspection when the sharps drawer was found to be unlocked.
8
9
10
11
12
13
14
Type B
08/19/2022
Section Cited

1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This regulation was not met as evidensed by, LPA observed miscellaneous debris with jagged edges and piles of trash.

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3