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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500309303
Report Date: 10/13/2021
Date Signed: 11/02/2021 02:27:05 PM

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:J & L GUEST HOMEFACILITY NUMBER:
500309303
ADMINISTRATOR:ANITA NIELFACILITY TYPE:
740
ADDRESS:237 S ABBIE STREETTELEPHONE:
(209) 527-2765
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:32CENSUS: 27DATE:
10/13/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anita NielTIME COMPLETED:
03:00 PM
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Unannounced case management visit made out to this facility on 10/13/2021 by LPA Charlie Yang and Tirzah Hubbard. LPAs were met by the facility designated Administrator, Anita Niel, and other members from the California Department of Public Health and Stanislaus County Health Department.
The purpose of this visit was to tour the facility and review the physical plant in response to the recent increase in COVID related resident and personnel cases.
Tour of the facility was conducted.

Exit Interview was conducted by Nurse Kristi Olguin, California Department of Public Health, and Medical Investigator Gorlia Xiong, Stanislaus County Health Department, with tips and recommendations related to reducing the number of COVID cases.

A copy of this report will be scanned and sent over to the facility designated Administrator, Anita Niel, due to COVID related concerns while at this facility. As a result, Anita Niel will have to sign the scanned copy and resubmit back to this LPA. Administrator signature is on file.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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