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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005071
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:11:18 PM

Document Has Been Signed on 09/08/2022 02:11 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:SONIA'S CARE HOME 2FACILITY NUMBER:
397005071
ADMINISTRATOR:GAPASIN, SONIAFACILITY TYPE:
740
ADDRESS:8240 RICHLAND DRIVETELEPHONE:
(209) 609-9342
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Criselda Paltep - Direct Care StaffTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct at Required 1 Year Annual Inspection Visit. LPA was greeted by staff above and allowed entrance to the facility. LPA informed purpose of today's visit. This facility is a single dwelling with 5 residents who are Valley Mountain Regional Center clients - level 3. Administrator Certificate # 6016991740 expiration on 7/24/20.

LPA and staff toured the facility inside and outside making a health and safety inspection. Inside temperature at 68 degrees. Hot water temperature was measured at (108.2) degrees Fahrenheit in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility was clean and odor free. LPA toured the kitchen and plenty of perishable and non-perishable foods. Medication locked in the kitchen cabinet. First Aid supplies and Manual observed in First Aid station. LPA observed poster required on the wall quite room area/office area. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers last serviced 4/13/222. Smoke and carbon monoxide detectors are in compliance with fire safety. There are no bodies of water present. Outside: Shaded area and furniture provided.

LPA reviewed four (4) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.
LPA reviewed two (2) resident files and all documents required by Community Care Licensing (CCL) were in facility files.
LPA requested the following documents to be submitted via email by October 26, 2022: LIC 308, LIC 400, LIC 610D, Facility Program/Plan of Operation, and Surety Bond.
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with staff and a report was left with staff.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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