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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392701577
Report Date:
02/19/2025
Date Signed:
02/24/2025 07:38:49 AM
Document Has Been Signed on
02/24/2025 07:38 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:
WAILEA CARE
FACILITY NUMBER:
392701577
ADMINISTRATOR/
DIRECTOR:
DAMRICHOB, AMNUAYCHAI
FACILITY TYPE:
740
ADDRESS:
2426 ALPINE AVE
TELEPHONE:
(209) 207-4567
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95204
CAPACITY:
6
CENSUS:
0
DATE:
02/19/2025
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:
A.Damrichob
TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Albert Johnson conduct a Pre-Licensing Inspection.
LPA was unable to conduct the inspection due to the power being off for power pole replacement. LPA observed there are no residents at this time.
The inspection will have to be continued on Friday 2/21/2025.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Albert Johnson
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/19/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/19/2025
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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