<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005339
Report Date: 05/14/2024
Date Signed: 05/14/2024 12:05:38 PM

Document Has Been Signed on 05/14/2024 12:05 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STARTING OUTFACILITY NUMBER:
397005339
ADMINISTRATOR/
DIRECTOR:		MIA CHATMAN-JAMESFACILITY TYPE:
775
ADDRESS:41 W YOKUTS AVENUETELEPHONE:
(209) 476-1170
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 120CENSUS: DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Mia Chatman-James/ Program ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/9/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Mia Chatman- James/ Program Manager.

The facility is a two story structure with wheelchair accessibility. LPA observed all required signage, including license to be prominently posted. LPA toured the facility indoors and outdoors including but not limited to seven classrooms for activities, four restrooms, staff office, break room, kitchen and storage areas. LPA observed tables and chairs to serve the capacity of the day program. LPA observed medications room locked with a medications cart to store centrally stored medications,

Hot water temperature was measured at 112 degrees Fahrenheit in resident's bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers are current and in compliance with fire safety. Fire drill was conducted on 4/2024, Smoke detector and Carbon dioxide monitor present. LPA reviewed 5 resident and 5 staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete.

No deficiencies were cited as a result of today's visit. An exit interview was conducted and a report was left with the facility with appeal rights
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1