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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005617
Report Date: 12/01/2021
Date Signed: 12/01/2021 11:48:30 AM

Document Has Been Signed on 12/01/2021 11:48 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:WALTERS RESIDENTIAL HOME CAREFACILITY NUMBER:
397005617
ADMINISTRATOR:MOSES WALTERS SR.FACILITY TYPE:
735
ADDRESS:2746 ABRUZZI COURTTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
12/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:David BlaineTIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check.

LPA confirmed that staffing is sufficient today and there are no unmet needs for the residents in care. The facility is staffed to provide no gaps between shifts

The facilities hot water measured at 116.5. LPA reviewed new residents facility file. During the review LPA observed that the Physician's report identified that R1 is "able to go into the community unassisted". R1 is living in a level 4I home, has some considerable lack of safety awareness and would be a danger to himself or others if allowed to be in the community unassisted. This should be reviewed by the physician and revised accordingly.

Health and Safety check has concluded for today. The overall safety of the facility including food supply, physical plant and staffing.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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