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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001415
Report Date: 04/12/2022
Date Signed: 04/12/2022 02:52:29 PM

Document Has Been Signed on 04/12/2022 02:52 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:UCP OF SAN JOAQUIN.CALAVERAS AND AMADORFACILITY NUMBER:
397001415
ADMINISTRATOR:TONISHA MIXONFACILITY TYPE:
775
ADDRESS:7616 PACIFIC AVENUE #A6TELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 87CENSUS: 2DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tonisha MixonTIME COMPLETED:
02:50 PM
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On 4/12/22 at 12:45pm, Licensing Program Analyst (LPA) Maja Jensen arrived unannounced to conduct a required one year annual visit. LPA Jensen met with Administrator Tonisha Mixon and explained the purpose of today's visit.

The facility is in a single story building and there is currently one central entry point. LPA Jensen observed an automated hand sanitizer combination temperature screening device fixed to the wall at the front entrance. The facility has an approved mitigation plan and a designated infection control coordinator. There are currently 2 clients attending program in person and 60 clients receiving services through zoom or receiving packets. LPA Jensen toured the facility including but not limited to restrooms, kitchen, personal care areas, activity areas, computer aided technology lab, breakroom, individual conditioning room and office. COVID related signage was observed to be posted the throughout the facility. Emergency water and a PPE supply in excess of 30 days was observed on premises.

LPA Jensen measured water temperature in bathroom at 107.7 degrees and 107.5 degrees in the kitchen. The facility does not provide meal service and the kitchen is used to store food the client brings in or for training and activity purposes. A medication storage unit was observed with a double locking system however no clients are currently taking medication. LPA Jensen reviewed the activity schedule, Emergency Disaster Plan, License, facility sketch, personnel report, one staff file and one resident file. The documents reviewed were in found to be in compliance.

LPA Jensen observed two first aid kits that were complete. The facility conducts fire drills monthly which exceeds the regulatory requirements. The fire extinguisher was last serviced in March of 2022.

No deficiencies were cited as a result of today's visit. An exit interview was conducted and a copy of the report was given to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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