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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 08/09/2023
Date Signed: 08/09/2023 01:11:12 PM

Document Has Been Signed on 08/09/2023 01:11 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:MELMAR'S GUEST HOME #3FACILITY NUMBER:
397001192
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:5465 GOVERNOR CIRCLETELEPHONE:
(209) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ildefonso LetranTIME COMPLETED:
01:00 PM
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On 8/9/2023 at 10:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct a required annual inspection visit. LPAs met with the assistant administrator Ildefonso Letran and explained the purpose of the visit. Administrator Maricor Camero was made aware of LPAs visit and purpose.

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. 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. The hot water temperature in the residents’ shared bathroom was measured between 105 and 120 degrees Fahrenheit. The fire extinguisher was last inspected on 3/10/2023 and all smoke alarms and carbon monoxide alarms were tested successfully. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Facility has an emergency food supply. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. All toxins and other dangerous items including sharp objects were locked and inaccessible. Medication storage area was observed to be locked and inaccessible. First aid kit was observed to have adequate supplies and accessible to staff.

All staff noted on LIC 500 contained criminal background clearances. LPA completed 2 staff interviews. {Cont. on 809C}
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MELMAR'S GUEST HOME #3
FACILITY NUMBER: 397001192
VISIT DATE: 08/09/2023
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Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA requested an updated copy of LIC 308 and LIC 500, and current liability insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to the assistant administrator Ildefonso Letran.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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