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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002232
Report Date: 11/20/2023
Date Signed: 11/20/2023 03:22:21 PM

Document Has Been Signed on 11/20/2023 03:22 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:DE ORO GUEST HOME #2FACILITY NUMBER:
397002232
ADMINISTRATOR:DORIS B MADRIDFACILITY TYPE:
735
ADDRESS:1648 KNICKERBOCKER COURTTELEPHONE:
(209) 670-4458
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
11/20/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Nellen Van De PolTIME COMPLETED:
03:30 PM
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On 11-20-23 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a licensee initiated case management. LPA and Licensee discussed preventative measures regarding absence without leave (AWOL). Additionally, LPA and Licensee reviewed regulation on care and supervision as well as facility house rules pertaining to sign in and sign out procedures as well as resident rights. Licensee also discussed during case management the importance of knowing resident whereabouts and associated reporting requirements.

Licensee was made aware of the necessity for regularly updating needs and service plans and staffing plans for purposes of providing adequate care and supervision

No citations issued today. An exit interview was conducted with Nellen Vane De Pol and a copy of this report was provided to Nellen.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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