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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001192
Report Date: 02/15/2024
Date Signed: 02/16/2024 12:30:46 PM

Document Has Been Signed on 02/16/2024 12:30 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:
02/15/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Ildefonso Letran TIME COMPLETED:
07:00 PM
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On 02/15/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a health and safety visit. LPA met with Staff member, Ildefonso Letran and explained the purpose of the visit.
The purpose of this visit to conduct a health and safety visit. There was one other person present at this facility at this time, Aida Cachola.

There were currently 5 residents present at this home. However, it was learned that 3 residents from another facility have been dropped off at this facility at this time. One other resident is also residing with the residents from another facility until they are finished with renovations.

A tour of the facility was conducted.
LPA toured 3 shared resident bedrooms. All rooms are clean and sanitary and meet their needs at this time.
LPA observed 6 resident watching tv in the main living room. Furniture was observed to be in good repair.
LPA observed a sufficient amount of 2 day perishable and 7 day non perishable food supply at this time.
LPA was able to confirm that all residents have eaten and have snacks accessible at all time.
Residents were observed to be in overall good health.
Toxins were observed to be locked and made inaccessible. Hot water was within the required range at this time.

The department will continue to monitor the situation with health and safety checks at this time.
Based on the observations made during this visit, there are no deficiencies cited during this visit. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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