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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700225
Report Date: 03/02/2022
Date Signed: 03/03/2022 07:05:47 AM

Document Has Been Signed on 03/03/2022 07:05 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MONA LIZAFACILITY NUMBER:
392700225
ADMINISTRATOR:SALEH, MOTHANNAFACILITY TYPE:
740
ADDRESS:1552 MIDDLE FIELD AVETELEPHONE:
(209) 910-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Mothanna Saleh, AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual Inspection. Facility Administrator Mothanna Saleh was informed of the purpose of the visit and was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a written mitigation plan (LIC 808) and LPA reviewed and discussed the plan and discussed current Licensing guidance.

LPA toured the facility and reviewed the Mitigation Plan as well as discussing COVID Training Procedures during the Inspection. Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire extinguishers were serviced on July 23,2021 are in compliance at tis time and are due to be serviced this month. Facility has carbon monoxide detectors. Medication were locked and facility was determined to have an adequate food supply. Facility's PPE supplies were observed and determined to be adequate for a 30 supply. The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are 5 clients in the home and three client bedrooms. Water was tested at 116.5 degrees.

LPA observed the following posted in the facility: Hand washing and visitation policies, Visitation signs. Resident Personal Rights, Evacuation Routes and facility license were all posted as required. Current LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days.

Exit interview held with Mr. Saleh and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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