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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001819
Report Date: 09/09/2022
Date Signed: 09/09/2022 10:08:49 AM

Document Has Been Signed on 09/09/2022 10:08 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:CARPENTER GUEST HOMEFACILITY NUMBER:
397001819
ADMINISTRATOR:HERMIGINIO JOSEFACILITY TYPE:
735
ADDRESS:2482 CARPENTER ROADTELEPHONE:
(209) 462-4239
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 15CENSUS: 11DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Allan Jose - House ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct an Required 1 Year Annual Inspection Visit. LPA met with house manager and explained the purpose of the visit.

LPA and house manager inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108.8 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. LPA was able to review a current Surety bond for the facility, bond expires on December 1, 2024. Fire extinguishers inspected 8/5/2022 and smoke detectors are operational. LPA observed carbon monoxide detectors in the facility. Fire drill was conducted on 8/31/2022.

LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident and 3 staff files, including criminal record clearances. The first aid kit was checked and is complete.
LPA requested the following documents to be submitted via email by October 25, 2022: LIC 400, Copy of Surety Bond, LIC 500, LIC 610D, and Facility Program/Plan of Operation. ruth.wallace@dss.ca.gov

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
Exit interview conducted with and appeal rights given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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