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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 07/03/2023
Date Signed: 07/03/2023 01:19:51 PM


Document Has Been Signed on 07/03/2023 01:19 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:STETSON COURT LIVINGFACILITY NUMBER:
397005195
ADMINISTRATOR:GAOIRAN, CHRISTIANFACILITY TYPE:
740
ADDRESS:3913 STETSON COURTTELEPHONE:
(408) 876-9445
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
07/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Geline ArtuzTIME COMPLETED:
12:51 PM
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LPA Albert Johnson made an unannounced health and safety check. LPA met with Staff.

LPA checked the medications, menu, food/snacks and staff /resident files. Staff confirmed that 1 resident has moved out which brings the census to 5. The residents appear to be in good health at this time and there are no immediate safety concerns.

The facility does not have an activity calendar (not required for a six bed facility 87219(d)) and the residents confirmed that there are no coordinated activities, however, the residents have the option to listen to music, walk in the back yard, explore the internet on their tablets or watch television. The residents on-going or annual appraisals are written on the "Pre- appraisal form" the facility is using the wrong form to document the reappraisals.

The following forms need updating and submitted to CCLD by 07/10/2023:
LIC 308- Designation of Administrative Responsibility
LIC 500 - Personnel Report with the Administrator hours included

Exit interview conducted advisory given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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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