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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002220
Report Date: 10/17/2024
Date Signed: 10/18/2024 10:51:55 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/18/2024 10:51 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:PERSON CENTERED SERVICES, INC #2FACILITY NUMBER:
397002220
ADMINISTRATOR/
DIRECTOR:		ANN MARRIOTTFACILITY TYPE:
775
ADDRESS:4155 N. EL DORADO STREETTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 135CENSUS: 79DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:S. BrayTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Shelly Bray and explained the purpose of the visit.

The facility is licensed for 120 ambulatory and 10 non-ambulatory client. The facility currently has 79 clients in attendance today. LPA Johnson 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.

Hot water temperature was measured at 113.5 degrees Fahrenheit in resident bathroom sink in the converted wood shop , which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are operational.

LPA reviewed 15 resident and 5 staff files, including criminal record clearances. First aid kit was checked and is complete. LPA observed smoke detectors and carbon monoxide detectors in the facility rooms. Fire drill was conducted on 9/30/2024

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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