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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002666
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:42:02 AM

Document Has Been Signed on 01/20/2023 10:42 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:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Marcelina LaguaTIME COMPLETED:
10:45 AM
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On 1-20-23 at 10:19am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. LPA met with Administrator Marcelina Lagua and explained the purpose of the visit. The purpose of today's visit is to amend the annual visit conducted on 1-19-23. Document was amended and signed by Administrator.

An exit interview was conducted with Marcelina Lagua and a copy of this report was left with Marcelina.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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