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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202975
Report Date: 10/30/2024
Date Signed: 10/30/2024 12:59:37 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/30/2024 12:59 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:UNITED CEREBRAL PALSY, PROGRAM WITHOUT WALLSFACILITY NUMBER:
397202975
ADMINISTRATOR/
DIRECTOR:
JOANNE JOHNSONFACILITY TYPE:
775
ADDRESS:6709 PLYMOUTH ROAD, SUITE CTELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 45CENSUS: 29DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:SerenaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Serena and explained the purpose of the visit. Later joined by Shirley (SPM).

LPA and Staff inspected the physical plant including but not limited to the kitchen, Activities room, resident bathrooms, medication rooms, and outside front courtyard. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. Hot water temperature was measured at 110.5 degrees Fahrenheit in resident's bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers, smoke detectors and carbon monoxide detector were in compliance with fire safety. LPA observed (PRN) centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 8 resident and 4 staff files, including criminal record clearances. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited today. (Advisories given) Exit interview held with Staff and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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