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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005036
Report Date: 08/12/2022
Date Signed: 08/14/2022 03:50:15 PM

Document Has Been Signed on 08/14/2022 03:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MICHAEL'S RESIDENTIAL HOME CARE, INC.FACILITY NUMBER:
397005036
ADMINISTRATOR:OGBUEHI, VICTORIAFACILITY TYPE:
735
ADDRESS:1152 RIVER CREST COURTTELEPHONE:
(209) 323-5966
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
08/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Nora GardoseTIME COMPLETED:
02:45 PM
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LPA Albert Johnson arrived at the care home today and met with caregiver to conduct a plan of correction (POC) visit in relation to a citation issued during an annual required inspection on 8/04/2022.

LPA toured the facility and checked food supply. Based upon this inspection, the LPA observed the following:

*Deficiency cited under Title 22 Regulation have been cleared. Licensee complied with the terms of the POC by POC due date.

Deficiencies cleared.

POC letter printed.

Exit interview.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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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