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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001458
Report Date: 08/05/2022
Date Signed: 08/05/2022 12:01:46 PM

Document Has Been Signed on 08/05/2022 12:01 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:TACSION'S GUEST HOME #3FACILITY NUMBER:
397001458
ADMINISTRATOR:TACSION, ROBERTFACILITY TYPE:
735
ADDRESS:2344 WAGNER HEIGHTSTELEPHONE:
(209) 952-6037
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Christopher TacsionTIME COMPLETED:
12:15 PM
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On 8/5/22 at 9:45am Licensing Program Analyst (LPA) Kevin Gould arrived at Tacsion's Guest Home #3 for the purpose of conducting a required 1 year annual inspection. LPA met with staff Christopher Tacsion and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA inspected the back yard and observed the existing fence has been removed and new fence post have been installed to complete a new fence along the left hand side of the home. LPA was informed the work began this week and is anticipated to be completed by 8/8/22.

LPA measured the water temperature, temperature measured at 105 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA conducted file review for all residents and observed the facility is currently retaining four (4) residents over the age of 60. LPA informed facility that they are currently out of compliance as the residents aged up while in placement. LPA informed licensee of the steps required for an exception to ensure the facility remains in compliance with tittle 22 regulations.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, Current Administrator Certificate and Client Roster.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TACSION'S GUEST HOME #3
FACILITY NUMBER: 397001458
VISIT DATE: 08/05/2022
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Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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