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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005336
Report Date: 03/14/2022
Date Signed: 03/14/2022 11:35:15 AM

Document Has Been Signed on 03/14/2022 11:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:RM UGALE CARE HOMEFACILITY NUMBER:
397005336
ADMINISTRATOR:MAGSAYO-UGALE, MAYBELYNFACILITY TYPE:
740
ADDRESS:110 E. MT. DIABLO AVENUETELEPHONE:
(209) 836-5215
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Romeo Constantino and Anges PondocTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Albert Johnson conducted a case management visit to check the POC deficiencies that were cited on 12/20/2021.

LPA met with Staff (Romeo Constantino and Anges Pondoc), LPA toured the facility.

LPA observed all deficiencies have been corrected. POC cleared on this date.

No other deficiencies observed or cited.

A copy of this report was left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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