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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397002220
Report Date:
12/04/2024
Date Signed:
12/04/2024 01:48:35 PM
Document Has Been Signed on
12/04/2024 01:48 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
PERSON CENTERED SERVICES, INC #2
FACILITY NUMBER:
397002220
ADMINISTRATOR/
DIRECTOR:
ANN MARRIOTT
FACILITY TYPE:
775
ADDRESS:
4155 N. EL DORADO STREET
TELEPHONE:
(209) 466-2448
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95207
CAPACITY:
135
CENSUS:
DATE:
12/04/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:
Ben Guzman
TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct an interview with a resident regarding a complaint at GIER CARE HOME II. LPA was greeted by Licensee staff explained the reason for the visit.
LPA Lewis conducted the interview with R1.
An exit interview was held and a copy of this report was given.
SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Kesha Lewis
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
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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