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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005130
Report Date: 02/14/2024
Date Signed: 02/14/2024 11:41:08 AM

Document Has Been Signed on 02/14/2024 11:41 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: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:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:RAKSMEY ROEUM-CASTLEMAN - ADMINISTRATORTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with administrator and explained the purpose of the visit.

LPA and administrator 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 six Social Rehabilitation Facility with a current census of five. Facility has 6 bedrooms, 3 bathrooms. There is a dining area off the kitchen and a formal living room for residents. Common touch surfaces are cleaned after each use. All sharp objects, toxins, and other dangerous items are inaccessible to residents in care. Fire drill last conducted on 1/1/2024.

LPA measured the hot water temperature in resident's bathroom at 110.9 degrees Fahrenheit which is within the required range of 105 to 120 degrees. LPA observed sufficient seven day non-perishable and two day perishable food supplies. 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 last inspected 1/31/2024. Facility has an emergency food and water kit.
LPA reviewed five residents and five staff charts. All contents including first aid certifications, and fingerprint clearances in place. All sharp objects, toxins, and other dangerous items are inaccessible to residents in care.

LPA requested the following updated documents via email to community care licensing by February 15, 2024: LIC 308 Designation of Administrator, LIC 500 Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance.
ruth.wallace@dss.ca.gov

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Administrator. A report and LIC 811(Confidential Names) was left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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