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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392700997
Report Date:
12/11/2024
Date Signed:
12/11/2024 02:56:49 PM
Document Has Been Signed on
12/11/2024 02:56 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:
NOVELLUS STOCKTON
FACILITY NUMBER:
392700997
ADMINISTRATOR/
DIRECTOR:
CHANTLLE HUDSON
FACILITY TYPE:
740
ADDRESS:
6037 N. PERSHING AVENUE
TELEPHONE:
(209) 951-2030
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95207
CAPACITY:
160
CENSUS:
66
DATE:
12/11/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:
Nellie Gomez
TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility and met Nellie to conduct an unannounced POC visit from the annual completed on 11/25/2024 and case management visits on 7/29/2024 and 6/07/2024.
The facility submitted required corrections as required by due dates
POC's corrected
Deficiencies cleared
Exit interview
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Albert Johnson
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/11/2024
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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