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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700225
Report Date: 06/05/2024
Date Signed: 06/10/2024 10:19:10 PM

Document Has Been Signed on 06/10/2024 10:19 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:MONA LIZAFACILITY NUMBER:
392700225
ADMINISTRATOR/
DIRECTOR:		SALEH, MOTHANNAFACILITY TYPE:
740
ADDRESS:1552 MIDDLE FIELD AVETELEPHONE:
(209) 910-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 6DATE:
06/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:VickyTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 5/6/2024 LPA Albert Johnson contacted to the facility to complete a health and safety visit.

LPA confirmed that staffing is sufficient today and there are no unmet needs for the residents in care.

Health and Safety check has concluded for today. The overall safety of the facility including food supply, physical plant and staffing.

No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted..
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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