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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701376
Report Date: 04/12/2024
Date Signed: 04/12/2024 10:09:43 AM

Document Has Been Signed on 04/12/2024 10:09 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MY JOURNEY CARE HOMEFACILITY NUMBER:
502701376
ADMINISTRATOR/
DIRECTOR:		XIONG, MAIFACILITY TYPE:
735
ADDRESS:4213 NOAH COURTTELEPHONE:
(209) 401-3454
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 4CENSUS: 0DATE:
04/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mai Xiong, Administrator/Applicant
Nancy Xiong, Applicant		TIME VISIT/
INSPECTION COMPLETED:
10:05 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 4
Census (if any clients in care): none
COMP II Participants: Mai Xiong, Administrator/Applicant
Nancy Xiong, Applicant
Interview Method: Telephone interview

On April 12, 2024, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicants and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicants and Administrator. Copy of report sent via email and informed to return sign copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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