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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002666
Report Date: 01/19/2023
Date Signed: 01/20/2023 10:40:54 AM

Document Has Been Signed on 01/20/2023 10:40 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:GOVERNOR CIRCLE CARE HOMEFACILITY NUMBER:
397002666
ADMINISTRATOR:LAGUA, MARCELINAFACILITY TYPE:
735
ADDRESS:5435 GOVERNOR CIRCLETELEPHONE:
(209) 954-0327
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Laurie FajardoTIME COMPLETED:
02:15 PM
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On 1/19/23 at 12:44pm Licensing Program Analyst (LPA), Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the lead caregiver Laurie Fajardo and explained the purpose of the visit. Administrator Marcelina Lagua was made aware of LPA's visit and purpose and gave permission for lead caregiver to accompany LPA and sign in her absence.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. Facility has 4 bedrooms, 2 shared and 2 private. Facility also has 2 bathrooms for client use. There is a dining area off the kitchen and a formal living/tv area.
The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 1/5/23. Facility has an emergency food and water kit and 30-day supply of PPE. Records for Staff1 (S1), S2, S3, S4, and S5 reviewed. First aid/CPR certification are current. All staff COVID-19 vaccination records verified. Fingerprint clearances were verified for all staff.
Per California Code of Regulations, Title 22, division 6 no deficiencies were observed during this visit. Exit interview was held with Laurie Fajardo and a report was given to Laurie. Acknowledged by Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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