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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701000
Report Date: 10/01/2024
Date Signed: 10/01/2024 10:00:19 AM

Document Has Been Signed on 10/01/2024 10:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VILLA THERESA 2 CARE HOMEFACILITY NUMBER:
392701000
ADMINISTRATOR/
DIRECTOR:		ALAN, JOSE FFACILITY TYPE:
740
ADDRESS:3028 MCCOOK WAYTELEPHONE:
(209) 462-4239
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sharon Fernandez, House ManagerTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 10/01/24, LPA Campbell arrived to the facility unannounced. LPA Campbell met with Sharon Fernandez, House Manager and stated the purpose of the visit. LPA Campbell conducted a case management to obtain a signature for an annual deficiency conducted on 09/26/24. LPA Campbell conducted a tour of the facility Staff confirmed that debris had been removed from the backyard as discussed during the annual inspection.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
A hard copy of this report and updated deficiency page have been left with the House Manager, Sharon Fernandez.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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