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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700746
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:16:31 PM

Document Has Been Signed on 10/27/2022 04:16 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:ASPIRE RESIDENTIAL CARE, LLCFACILITY NUMBER:
392700746
ADMINISTRATOR:FARKAS, KHANHFACILITY TYPE:
740
ADDRESS:121 MCKELVEY AVENUETELEPHONE:
(209) 834-7359
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Khanh FarkasTIME COMPLETED:
04:20 PM
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On 10/27/22 at 3:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to assist a resident with obtaining documents from her previous facility. LPA Jensen met with licensee Khanh Farkas and explained the purpose of today's visit.

Resident 1 (R1) requested LPA Jensen's assistance in obtaining her medical records from the facility she previously resided at. LPA Jensen requested a copy of R1's resident file from Sunny Place of Stockton. Sunny Place of Stockton emailed the records to LPA. LPA Jensen handed R1 all the records that were provided to the LPA by email..

An exit interview was conducted and a copy of this report was given to Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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