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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397202998
Report Date:
09/16/2024
Date Signed:
10/01/2024 11:26:40 AM
Document Has Been Signed on
10/01/2024 11:26 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
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:
09/16/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:
care staff Edwin Valdez
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conducted an case management visit. LPA met with direct care staff Edwin Valdez 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:
09/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/16/2024
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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