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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203009
Report Date: 12/03/2021
Date Signed: 02/16/2022 12:08:50 PM

Document Has Been Signed on 02/16/2022 12:08 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:MICHAEL'S RESIDENTIAL HOME CAREFACILITY NUMBER:
397203009
ADMINISTRATOR:OGBUEHI-NZAMBI, VICTORIAFACILITY TYPE:
735
ADDRESS:5125 JETTY DRIVETELEPHONE:
(209) 234-2215
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
12/03/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Jemimah Githua and Jacutin MerlaTIME COMPLETED:
02:30 PM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the case management visit conducted on 10/05/2021.

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited on 10/05/2019 has not been cleared.

Deficiency cited under Title 22 Regulations has not been cleared.

Facility will provided a POC letter identifying when current IPP's for residents with outdated IPP will be available by 12/7/2021.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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