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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001564
Report Date: 06/28/2023
Date Signed: 06/28/2023 11:04:12 AM

Document Has Been Signed on 06/28/2023 11:04 AM - 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:KATHERINE WAY MANORFACILITY NUMBER:
397001564
ADMINISTRATOR:EDDIE ALICANTEFACILITY TYPE:
735
ADDRESS:1020 KATHERINE WAYTELEPHONE:
(209) 475-1190
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 3DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nenita Juan - Direct Care StaffTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required one year annual inspection visit. LPA was met by direct care staff who informed administrator of the LPA's visit. LPA explained the purpose of the visit to staff.

LPA Wallace and direct care staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a six bed facility with a current census of three There are three client bedrooms and two client bathrooms There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Toxins are locked up. The facility submitted a LIC 808 mitigation plan, which was approved.
LPA observed the facility to have adequate food supply of seven days non-perishables and two days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings
Hot water temperature was measured at 112.6 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.
Fire extinguishers last inspected on June 19, 2023 and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medications. LPA reviewed two resident and three staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA observed a carbon monoxide detector in the facility.

LPA received updated copies of the following documents:
LIC 308 - Designation of Administrator and Administrator Certificate

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies. Exit interview conducted with direct care staff and copy of report provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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