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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005130
Report Date: 12/08/2021
Date Signed: 12/08/2021 03:00:30 PM

Document Has Been Signed on 12/08/2021 03:00 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:TELECARE SAN JOAQUIN CRISIS RESIDENTIAL SERVICESFACILITY NUMBER:
397005130
ADMINISTRATOR:RAKSMEY ROEUM-CASTLEMANFACILITY TYPE:
772
ADDRESS:5634 JEREMY WAYTELEPHONE:
(209) 888-4969
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 5DATE:
12/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Raksmey Roeum-Castleman, AdministratorTIME COMPLETED:
03:15 PM
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On 12/08/2021 at 2:00 pm, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a case management visit. LPA met with Administrator, Raksmey Roeum-Castleman . LPA explained the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients. During the visit, LPA requested Personnel Report (LIC 500) and Client Roster (LIC 9020) for 2021 regarding a complaint investigation.

No deficiencies cited during inspection. Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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