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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001463
Report Date: 10/18/2022
Date Signed: 10/18/2022 04:39:37 PM

Document Has Been Signed on 10/18/2022 04:39 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:NEW HOPE GUEST HOMEFACILITY NUMBER:
397001463
ADMINISTRATOR:ROBERT FELIXFACILITY TYPE:
735
ADDRESS:526 PALOMA AVENUETELEPHONE:
(209) 478-3089
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 8DATE:
10/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Administrator/Licensee Robert Felix TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an case management visit. LPA met with Administrator/Licensee Robert Felix and explained the purpose of the visit. Census 8

Licensing (CCL) received a LIC 624 that on 10/15/2022 the New Hope Guest Home-Balboa (Facility) had a small fire causing minimal damage to the facility. There were six clients at the facility at the time of the fire, which had to be placed at two different facilities. Four clients were place at New Hope Guest Home which already had a capacity of 4 of 6. With the four clients from the New Hope Guest Home- Balboa that would give the facility 8 clients for a capacity of 6 as of 10/18/2022.

Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted with Administrator/Licensee Robert Felix and a copy of the report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
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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Document Has Been Signed on 10/18/2022 04:39 PM - It Cannot Be Edited


Created By: Jason Lund On 10/18/2022 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME
FACILITY NUMBER: 397001463

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2022
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal
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Administrator/Licensee Robert Felix will remove one client to get into capacity.
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This requirement is not met as evidenced by:
LPA observed 8 Clients at the facility. The facility is licensed for 6. This poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022


LIC809 (FAS) - (06/04)
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