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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203015
Report Date: 11/13/2023
Date Signed: 11/13/2023 09:16:40 AM

Document Has Been Signed on 11/13/2023 09:16 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:CREEKSIDE GUEST HOMEFACILITY NUMBER:
397203015
ADMINISTRATOR:SHERON N. L. WOOFACILITY TYPE:
735
ADDRESS:3019 FAIRBURY LANETELEPHONE:
(209) 298-2267
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee - Dolfa BomarTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required annual inspection visit. LPA met with licensee and explained the purpose of the visit.

LPA and licensee inspected the physical plant including but not limited to the kitchen, resident bedrooms, staff room, two resident bathrooms, laundry area, and backyard area. LPA observed the facility to be free of odor. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers were last inspected on 8/16/23. Smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents.

LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed two resident and three staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Fire drill was conducted on .

LPA received the following updated document on today's date: LIC 308 - Designation of Administrator, LIC 500 - Personnel Summary, copy of administrator's certificate, and copy of surety bond

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 

Exit interview held with licensee. A report and LIC 811 (Confidential Names) was left at the facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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