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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393611645
Report Date: 10/14/2024
Date Signed: 10/14/2024 10:31:27 AM

Document Has Been Signed on 10/14/2024 10:31 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CAMP HUTCHINS OF LODI MEMORIAL HOSPITALFACILITY NUMBER:
393611645
ADMINISTRATOR/
DIRECTOR:		SANDRA ETHERTONFACILITY TYPE:
850
ADDRESS:125 SOUTH HUTCHINS STREETTELEPHONE:
(209) 334-2267
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 53TOTAL ENROLLED CHILDREN: 53CENSUS: 18DATE:
10/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Sandra JohnsonTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Erwin Tjhia met with Site Supervisor, Sandra Johnson to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing on 10/09/2024. LPA arrived at the facility and disclosed the purpose of the inspection. Criminal background clearances were verified.

LPA requested documentation of the facility roster, and supporting documentation pertinent to the investigation.

Facility Evaluation report was reviewed and discussed with Site Supervisor, Sandra Johnson. Exit interview was conducted. A Notice of Site Visit was posted by the LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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