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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005130
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:20:20 PM

Document Has Been Signed on 03/10/2022 03:20 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:
03/10/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jessica WhittingtonTIME COMPLETED:
03:30 PM
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On 3/10/21 at 1:35pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced inspection at Telecare San Joaquin Crisis Residential Services for the purpose on conducting a Plan of Correction (POC) inspection to ensure all staff files are complete and available for inspection.

LPA met with staff who provided LPA with the missing items requested by LPA. All staff files reviewed by LPA are now observed to be complete and well organized. LPA provided facility with POC clearance letter.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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