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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 02/06/2026
Date Signed: 02/06/2026 02:40:26 PM

Document Has Been Signed on 02/06/2026 02:40 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:ARLYN'S GUEST HOMEFACILITY NUMBER:
392700049
ADMINISTRATOR/
DIRECTOR:
DE LA CRUZ, ARLYN MFACILITY TYPE:
740
ADDRESS:1633 S STOCKTON STREETTELEPHONE:
(209) 392-7049
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 3DATE:
02/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Arlyn De La CruzTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility on 2/6/2026 at 9:45 am to conduct an annual inspection. LPA met with administrator Arlyn De La Cruz and explained the purpose of the visit.

2 clients have restricted conditions, both are diabetic one has additionally O2 administration. Arlyns guest home is an RCFE for the elderly/developmentaly disabled + dementia with a capacity of 6 nonambulatory and 2 hospice and a current census of 3 nonamb, 0 hospice. Exception paperwork will be filled out for the O2 administration.

Physical inspection included but was not limited to:
Kitchen,bedrooms, bathrooms, common areas, storage areas, the exteriors, and the evacuation route. facility is clean, traffic areas are unobstructed and well lit.
Kitchen has food storage for 2 days perishable and 7 days non perishable for 3 clients. LPA gave guidance to put "Staff" of staff foods. there is lockable storage for the medication, Per administrator, VMRC has said not to lock the cleaning matierials and knives. LPA gave guideance that knives and cleadning chemicals should be in lockable storage when outside of supervised use.
Bedrooms have required furniture and furnishings, including materess encasements, there exists duplicate linens.
bathrooms have functional hardware,
common areas and exteriors are free of trip hazzards and furnishings are in good repair,
evacuation route gate swings freely and latches closed, on one side on the building. a secondary gate does drag into the concrete. LPA gave guidance to monitor the situation.

Continued on c Page.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049
VISIT DATE: 02/06/2026
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Fire extinguisher was dated 12/12/25, Smoke/Co alarm was functional, water temperature was measured at 105-120*F.

Medication was checked against mars for 2 clients at random, found to be in agreement. LPA pointed out there are too many drugs for one of the clients, per administrator the excess will be destroyed and marked in the destruction record. LPA gave guidance that medication with variable dosage should not be given without a documented consultation from a licensed medical professional every time, and it would be improper for her as the licensee to make medical choices regarding the clients care, since she has a buisness interest in particular outcomes.

Client files were reviewed including but not limited to:
recent medical assessments, signed admission agreements, needs and servess plans, functional assessments and IPPs. documents are up to date and present. P+I was checked against balance statement for 1 clients, found to beholding cash over the balance sheet by about 50 cents. LPA gave guidance it should be tracked accurately.

Staff files were reviewed including but not limited to:
health screenings, initial and continued trainings, first aid training, and backround check clearances with the doj and fbi, were found to be present and up to date. LPA gave guidance that annual training topics should lean on developmentally disabled clients needs, and diabetic care. LPA gave guidance Any clients unplanned visit to the hospital/acute psychiatric should be reported to ccl within 7 days of the occurrence using the LIC 624 form.

Administrator files were reviewed, including but not limited to:
facility posters(ombudsman, client rights, family council, resident council, emergency/abuse services contacts, facility sketch with evacuation route, facility license, federal work rights, and administrators license()expires 11/23/25) are all in the staff room. Per administrator VMRC asked for posters to not be in the living space of the facility, LPA gave guidance that at least the ombudsman, client rights, emergency and abuse services contacts, and facility sketch with evacuation rout should be posted near the door. control of property, liability insurance, surety bond, were found to be present and up to date. administrators hiv training, infection control plan, evacuation plan, workers comp, should be emailed to the LPA. Gaurdian roster should be cleaned out at least once a year, but ideally when people come on or leave the company. noel.wolfpetersen@dss.ca.gov

3 interviews with clients, 1 interview with staff.

A copy of the report was read and given to the administrator, an exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC809 (FAS) - (06/04)
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