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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701577
Report Date: 02/21/2025
Date Signed: 02/24/2025 07:39:43 AM

Document Has Been Signed on 02/24/2025 07:39 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 CAREFACILITY NUMBER:
392701577
ADMINISTRATOR/
DIRECTOR:		DAMRICHOB, AMNUAYCHAIFACILITY TYPE:
740
ADDRESS:2426 ALPINE AVETELEPHONE:
(209) 207-4567
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 0DATE:
02/21/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:A. DamrichobTIME VISIT/
INSPECTION COMPLETED:
11:51 AM
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 Licensing Program Analyst (LPA) Albert Johnson arrived at for the purpose of conducting a pre-licensing inspection. LPA met with Licensee and together conducted a tour of the home.

LPA and licensee evaluated the physical plant to ensure the health and safety of future residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 120 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA and Licensee conducted component 3 orientation. LPA covered orientation for RCFE regulations, reporting requirements, common issues of facility operation.

Licensee has met all requirements to be licensed. LPA will contact CAB with notification on completed pre-licensing and component III orientation.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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