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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701163
Report Date: 06/07/2023
Date Signed: 06/07/2023 12:20:42 PM

Document Has Been Signed on 06/07/2023 12:20 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: 3DATE:
06/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rolando SantiagoTIME COMPLETED:
12:30 PM
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On 6/7/23 at approximately 10:15am Licensing Program Analyst Maja Jensen arrived at facility to conduct a case management related to an incident report for an occurrence on 5/27/23. Licensing Program Analyst Maja Jensen met with Licensee Rolando Santiago.

The Department received a report of an allegation of a resident inappropriately touching another resident. LPA Jensen interviewed 3 of 3 residents. LPA Jensen interviewed 2 of 2 staff members present at the time of the visit and the Licensee.

LPA Jensen reviewed the Resident file for R1 and R2. Based on the records reviewed and interviews conducted no deficiencies were identified..

An exit interview was conducted and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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