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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:39:37 AM

Document Has Been Signed on 06/16/2023 11:39 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:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 4DATE:
06/16/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Carrie MumphreyTIME COMPLETED:
12:00 PM
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On 6-16-23 at 10:05 am, Licensing Program Analysts ( LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA was greeted by Assistant Administrator Carrie Mumphrey, and LPA explained the purpose of the visit. Licensee William Puckett was notified of LPA's visit and purpose and stated he was on duty previous night shift.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 5-bed adult residential facility with a current census of 4. Facility has 4 bedrooms and 3 bathrooms. There is a formal living room and family/TV room for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. Resident rights posted. No obstructions to emergency exits noted.

The facility has submitted a COVID-19 mitigation plan. LPA observed the facility to have hand washing, COVID -19 informational, and social distancing signs posted throughout the facility. LPA observed facility to be clean and sanitary with no foul odors or disrepair items noted. There were 2 staff on duty during LPA's visit today. LPA reviewed 4 client records. All contents in place. Current behavior plans were observed in all records. LPA reviewed medication log book for consistency and accuracy.

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: INSPIRING CARE
FACILITY NUMBER: 397005738
VISIT DATE: 06/16/2023
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Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply during today’s visit. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in adequate repair. Facility has an emergency food and water kit. Fire extinguisher is fully charged and dated 5/22/23. Staffing schedule reviewed by LPA to reflect an Administrator on duty at least 40 hours per week.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Assistant Administrator Carrie Mumphrey

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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