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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005472
Report Date: 03/08/2022
Date Signed: 03/09/2022 07:07:59 AM

Document Has Been Signed on 03/09/2022 07:07 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:A DAY AWAYFACILITY NUMBER:
397005472
ADMINISTRATOR:LEAL-MALLETE, PENNYFACILITY TYPE:
775
ADDRESS:3550 WAGNER HEIGHTS RDTELEPHONE:
(209) 956-3400
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 15CENSUS: 0DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria BrownTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived to conduct an unannounced Annual inspection on this date. The Administrator for the facility, Dawn Shimel, was informed of the purpose of the visit and Maria Brown able to assist with the completion of the inspection focusing on the facility's infection control procedures for this adult day program. LPA also met with Memory Care Coordinator Maria Brown as well. At this time, the day program is not operating and there are no clients in the program. the facility is having a meeting the following week to determine the plans for the program and will inform Licensing after that meeting. The Residential Care Facility for the Elderly has submitted a mitigation plan and an updated plan for the day program will be submitted as well. Facility agreed to advise Licensing when the program opens again, possibly this summer.

LPA toured the facility. Smoke alarms are hard wired into the building and are operable. Facility has smoke detectors and heat detectors and built in sprinklers.Water temperature was measured at 118.5 degrees F.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Exit interview held with Maria Brown and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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