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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002220
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:11:30 PM

Document Has Been Signed on 09/14/2023 12:11 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:PERSON CENTERED SERVICES, INC #2FACILITY NUMBER:
397002220
ADMINISTRATOR:ANN MARRIOTTFACILITY TYPE:
775
ADDRESS:4155 N. EL DORADO STREETTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 135CENSUS: 85DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Shelly BrayTIME COMPLETED:
12:30 PM
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On 9/14/23 at approximately 9:40 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Program Director Shelly Bray and explained the purpose of today's visit.

The inspection tool was used during the course of this visit. The facility is licensed for 120 ambulatory and 10 non-ambulatory client. The facility currently has approximately 80 clients on any given operational day. LPA Jensen toured the interior of the facility and grounds. The grounds were observed to be clear of obstructions and shaded area and outdoor furniture is available for client outdoor activities.

LPA Jensen toured the interior office space, bathrooms and various classrooms. The water temperature in the bathroom was measured at 118 degrees and is in compliance. The thermostat was set at 74 degrees for teh comfort of the clients. During the course of this visit LPA Jensen observed a sewing class, a wood working class, a history and math class as well as a substance use recovery program that clients were actively participating in. LPA Jensen engaged with several clients and interviewed 3 clients. LPA Jensen also interviewed 3 staff members. 5 staff files and 5 client files were reviewed and found to be complete.

LPA Jensen observed the smoke detector and carbon monoxide detector to be in good working order. The fire extinguisher was last serviced in June of 2023 and is in compliance. The facility conducts monthly fire drills and maintains a log of all fire drills conducted. LPA Jensen verified the facility Automated External Defibrillator (AED) is maintained as required by regulation. The facility has 1st aid kits that are complete and in compliance. The facility was determined to be in substantial compliance. No deficiencies are being issued.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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