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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550312394
Report Date: 06/02/2022
Date Signed: 06/06/2022 12:31:40 PM

Document Has Been Signed on 06/06/2022 12:31 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:CIRCLE HOMEFACILITY NUMBER:
550312394
ADMINISTRATOR:DUNHAM, CHRISTINEFACILITY TYPE:
735
ADDRESS:15301 TUOLUMNE ROADTELEPHONE:
(209) 532-5411
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 4CENSUS: 2DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Christine DunhamTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility June 2, 2022 at 145 p.m.. to conduct the facilities annual inspection. LPA met with Licensee Christine Dunham Continual Administrator's Certification expires 02/24/2023. There are currently 2 residents who reside at this home.

LPA confirmed all facility staff has vaccine cards. LPA confirmed facility staff present is background cleared. LPA met with Licensee outside of the facility as it was discovered today both staff and one resident is COVID positive. LPA reviewed COVID protocols with Licensee Christine Durham and confirmed the facility has sufficient PPE, masks, COVID tests, and gloves. LPA confirmed the facility is clean and in good repair. LPA observed the facility has running water, and working utilities.


LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.


No Deficiencies cited according to Title 22 Regulations on today's date.

Exit interview conducted with Licensee Christine Durham and copy of report was emailed to Licensee Christine Durham.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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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