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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397001613
Report Date:
09/18/2024
Date Signed:
09/19/2024 10:52:49 AM
Document Has Been Signed on
09/19/2024 10:52 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER:
397001613
ADMINISTRATOR/
DIRECTOR:
MARIVIC TEANO-CHUA
FACILITY TYPE:
735
ADDRESS:
2002 E. HARDING WAY
TELEPHONE:
(209) 943-5420
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95205
CAPACITY:
15
CENSUS:
15
DATE:
09/18/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
05:30 PM
MET WITH:
Care Staff Flordeliza Agtang
TIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a case management visit. LPA met with Care Staff Flordeliza Agtang and explained the purpose of the visit. Census: 15
LPA conducted spoke with Care Staff Flordeliza Agtang regarding Client (C1) and Client (C2). C1 moved to the facility on 8/30/2024 and C2 moved in on 9/5/2024. She stated that have received all client’s medications and belongs and adjusting to the new facility. LPA spoke with C1 & C1 who stated the are adjusting to the new facility.
No deficiencies were observed during this visit. Exit interview was held and a copy of this report was given.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
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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