Community Care Licensing

Document Has Been Signed on 04/09/2024 09:00 AM - It Cannot Be Edited

FACILITY NAME:	NANTUCKET RESIDENCE, THE		FACILITY NUMBER:	392701156
ADMINISTRATOR/ DIRECTOR:	CECIL DE LARA		FACILITY TYPE:	740
ADDRESS:	3232 WISCONSIN AVE		TELEPHONE:	(209) 636-3456
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY: 6		CENSUS: 5	DATE:	04/08/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:06 PM
MET WITH:	De Lara		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual inspection conducted on 4/4/2024 . Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC. The following deficiencies, initially cited during a visit on 04/04/2024, have been cleared: Section Cited: 87303(e)(2) Date Due: 04/05/2024 Plan of Correction: Administrator sent staff to purchase a temperature gun and again lowered the thermostat during the tour and agreed to test the hot water for 3 days. Corrections: Cleared By Visit Clearance Date: 04/08/2024 Section Cited: 87615(a)(4) Date Due: 04/05/2024 Plan of Correction: Licensee/Administrator shall provide written proof of correction by close of business date of Proof of correction shall address the relocation of R1 and training deficiencies for administrator as well as licensee regarding prohibited health conditions. Corrections: Cleared By Visit Clearance Date: 04/08/2024

SUPERVISORS NAME: Lisa Rios LICENSING EVALUATOR NAME: Albert Johnson LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024