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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397202998
Report Date:
08/28/2024
Date Signed:
08/28/2024 01:43:25 PM
Document Has Been Signed on
08/28/2024 01:43 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:
J & R MAGSAYO HOME II
FACILITY NUMBER:
397202998
ADMINISTRATOR/
DIRECTOR:
MAGSAYO, RENDENTOR
FACILITY TYPE:
735
ADDRESS:
544 WEST FIFTH STREET
TELEPHONE:
(209) 937-9793
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95206
CAPACITY:
6
CENSUS:
5
DATE:
08/28/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:
Administrator Rendentor Magsayo
TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannouced to conducted an case management visit. LPA met with direct care staff and later with Administrator Rendentor Magsayo explained the purpose of the visit. Census:5
LPA Lund went to the facility to gather documentation for Client (C1).
No deficiencies were observed during this visit. Exit interview conducted.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Jason Lund
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
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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