<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203015
Report Date: 11/14/2024
Date Signed: 11/20/2024 12:17:01 PM

Document Has Been Signed on 11/20/2024 12:17 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:CREEKSIDE GUEST HOMEFACILITY NUMBER:
397203015
ADMINISTRATOR/
DIRECTOR:
SHERON N. L. WOOFACILITY TYPE:
735
ADDRESS:3019 FAIRBURY LANETELEPHONE:
(209) 298-2267
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Rose LacayangaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Johnson arrived to conduct an unannounced annual/random inspection on this date. LPA met with Staff and explained the purpose of the visit.

LPA 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 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and 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 2 resident and 2 staff file, 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 11/1/2024.

No deficiencies were cited per Title XXII and CCL regulations.

Exit Interview
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1