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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005617
Report Date: 01/17/2023
Date Signed: 01/19/2023 12:32:59 PM

Document Has Been Signed on 01/19/2023 12:32 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: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: 5DATE:
01/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Tanneh KoayenTIME COMPLETED:
11:00 AM
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LPA Johnson made a case management inquiry regarding a back ground check on ID#4600053982 and Case#7922232005.

The above Identified individual shall not be allowed on the facility premises nor have any contact with clients unless a criminal record clearance is obtained.

A copy of the closure letter was confirmed received with the Administrator.


Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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