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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005280
Report Date: 06/09/2022
Date Signed: 06/10/2022 08:35:05 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/10/2022 08:35 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:RIVERA'S CARE HOMEFACILITY NUMBER:
397005280
ADMINISTRATOR:RIVERA, ELIZABETH M.FACILITY TYPE:
735
ADDRESS:372 WEST DELHI STREETTELEPHONE:
(209) 467-3761
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Marilou Banes, CaregiverTIME COMPLETED:
03:03 PM
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Licensing Program Analyst (LPA) Albert Johnson made an unannounced visit to this facility to conduct an Annual Required visit.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are two bedrooms and one bathroom for clients. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathroom was in sanitary condition, properly maintained and the hot water temperature was observed to be 109.5 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non- perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to clients. LPA observe the backyard of the facility to be free of clutter and debris and there appeared to be no potential safety hazards to the clients. Smoke detectors are operational and care home also has a carbon monoxide detector. Fire extinguishers and first aid kit are maintained and ready for emergency use. Care home also conducts monthly fire/disaster drills.

LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA checked resident records for completeness and accuracy. Care home staff also has criminal record clearances and current first aid training on file.

No deficiencies cited during this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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