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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701163
Report Date: 02/07/2023
Date Signed: 02/07/2023 04:41:30 PM

Document Has Been Signed on 02/07/2023 04:41 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:RCFE CARE & RESPITE HOUSEFACILITY NUMBER:
392701163
ADMINISTRATOR:SANTIAGO, ROLANDOFACILITY TYPE:
740
ADDRESS:663 CHICAGO AVENUETELEPHONE:
(209) 207-4964
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 0DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rolando SantiagoTIME COMPLETED:
04:45 PM
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On 2/7/23 at approximately 3pm Licensing Program Analysts (LPAs) Maja Jensen and Kimberly Viarella arrived at facility announced to conduct a required one year annual visit. LPAs Jensen and Viarella met with Licensee Rolando Santiago and explained the purpose of today's visit. The Administrator holds a current Administrator's certificate # 6057104740 good through 9/14/24.

The facility is a single story building with 4 bedrooms. The grounds were observed to be free of debris and all paths were free of obstruction. There are no bodies of water on the property. The facility has a single point of entry with a COVID screening station upon entering. The facility was observed to be free of odor and sanitary. Sharp objects, toxins and medications all have designated storage areas that are kept locked. LPAs Jensen and Viarella observed COVID mitigation signs posted throughout as well as all other required postings. The LIC 610 was reviewed and determined to be in compliance. The facility sketch accurately depicts the usage of all rooms in the facility. The first aid kit was found to be complete with scissors, tweezers, thermometer and manual. The smoke detector and carbon monoxide detectors were tested and found to be in good working order. The fire extinguishers were last serviced February 9th of 2022 and are currently in compliance. The facility maintains in excess of a 7 day emergency supply of food and water. The faxcility was observed to maintain a 30 day supply of PPE.

The resident bedrooms were observed to be furnished with chairs, dressers, night stands and lamps for the comfort of the guests. There are night lights in the hallway and emergency lighting throughout. The facility has multiple common areas for activities and visitation. The bathrooms were observed to have non-slip flooring in the showers/bath and grab bars at the toilets and shower. The water temperature was measured at 109.8 degrees which falls within the required regulatory range of 105-120 degrees.

The facility was observed to be in substantial compliance. An exit interview was conducted and a copy of this report was given to Rolando Santiago.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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