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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001415
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:37:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/05/2023 12:37 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: 26DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shirley RidolosoTIME COMPLETED:
12:45 PM
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On 5/5/2023 at approximately 9:50am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a required 1 year annual visit. LPAs Jensen and Fain met with Senior Program Manager Shirley Ridoloso and explained the purpose of today's visit.

LPAs Jensen and Fain toured the physical plant including the activity rooms, computer lab, changing rooms, kitchen, and bathrooms. There are 26 clients attending program in person and another 34 clients engaging in day program remotely. All required signs are posted in prominent areas including but not limited to personal rights, employee rights, Ombudsman, COVID mitigation, Provider Information Notices and facility Sketch. The facility was observed to be sanitary and free of odor. The thermostats were set at a range of 68-69 degrees for the comfort of the clients. The facility smoke detectors and carbon monoxide detectors were tested and determined to be in good working order. The fire extinguishers were last serviced in March of 2023. There are two first aid kits that were observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual. The water temperature was measured in bathroom at 110 degrees Fahrenheit which falls within the required range of 105-120 degrees. Grab bars were observed in all bathrooms. Garbage cans with tight fitting lids are being utilized throughout the facility. There is an emergency supply of water on site. The facility maintains emergency lighting. The facility conducts regular disaster drills. There was a variety of activities available for clients including arts and crafts and activities for mobility development. During the course of the visit the clients were engaged in games and singing activities.

LPA Jensen reviewed 3 of 13 staff files and 5 of 26 client files. All files were found to be complete and in compliance.

The facility was determined to be in substantial compliance. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided.


SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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