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�A:tf CALIFORNIA.HEALTH AND WELFARE AGENCY `J C�DEOF PARTMENT CIAL ER ES APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY FOR THE ELDERLY LICENSE (See lnstructionsonBack) FOR DEPARTMENT USE ONLY REPLY TO: DISTRICT COUNTY. FACILITY NUMBER DATE ACTION TYPE: REVIEWED BY. FACILITY TYPE: I APPLICANT(S) " EIS)(PLEASE PRINT( 2. REQUESTED ACTION(CHECK ONE): ❑ D. CHANGEOF FACILITY TYPE JOSE C.L. GALVEZ / ❑ A. INITIAL APPLICATION ❑ E. CHANGE OF OWNERSHIP FLORENTINO C. MAMUYACI B. CHANGE OF CAPACITY( ❑ F. CHANGE WITHIN CORPORATION IMMACULADA G. MAMUYAC ❑ C. CHANGE OF LOCATION ❑ G. OTHER(Specify) 5. APPLICANT MAIUNG ADDRESS CITY STATE ZIP CODE AREA CODEITELEPHONE P.O.BOX 30835 STOCKTON CA 95213 (209 )463-7555 R APPLICATION A. INDIVIDUAL }{ B. PARTNERSHIP C. NON PROFIT CORP. FILED BY: D. PROFITCORP E. COUNTY F. OTHER PUBLIC AGENCY 5. FACILITY OR AGENCY NAME TOWN AND COUNTRY GUEST HOME 6, FACILITY STREET ADDRESS CITY COUNTY SAN ZIP CODE AREA CODEYTELEPHONE P2829 'SOUTH D STREET l STOCKTON JOA UIN 95206 1( 209 )463-7555 7. FACIUTY MMLING ADDRESS I CITY STATE ' CODE P.O.BOX 30835 STOCKTON CA 95213-0835 6. ADMINISTRATOR OR PERSON IN CHARGE OF FACILITY Of K.) TITLE JOSE C.L. GALVEZ ADMINISTRATOR 9 TYPEOFAGENCYORFACILITY - 10. TOTALREQUESTEOCAPACRY 11- FORCHLDREN'SFACILMES ® ADULT RESIDENTIAL I ElSMALLFAMILYHOME 40 0 ADULTS-ti ONLY: ❑ RESIDENTIAL FAGUTY{E DERLY ❑ SOCIAL REHABIUTATION AMBULATORY H NUMBER OF. ❑ 100L RESIDENTIALFACIUTYtHRONICAILY ILL ❑ FO6TER FAMILYAGENCY NUMBER OF❑ NONFAMF ANY) AGES0 ADULT DAY CARE (IF ANY) NONE THROUGH❑ OTHER ISPpNT THROIXiN ZI ❑ ADULT DAY SUPPORT CENTER NUMBER OF TRANSFER DEFENCE AND,OR BEDRIDDEN(IF ANY) 'NONE CHILDREN ❑ (AGES B GROUP HOME THROUGH 17) 12. DAYS AND HOURS OF OPERATION: t1 PROPERTY OWNERSHIP: MON THRU SUN/ 24 HOURS ® OWN ❑ RENT ❑ OTHER(SPECIFY) 15A NAME.ADDRESS AND PHONE NUMBER OF PROPERTY OWNER,IF RENTING OR LEASING: N/A 16 yWpA1S FACILITY PREVIOUSLY UCENSEDT IF YES,FACILITY NAME AND NUMBER: LICENSING AGENCY NAME: TaB;yki. ❑ NO TOWN AND COUNTRY GUEST HOME/#390305260 DSS-CCL U ISMAJORCONSTRUCTIONREOUIREOT DATE CONSTRLrTION TO BEGIN: APPROX I JANUARY, 1998 16. SOURCE OF WATER FOR HUMAN CONSUMPTION ❑ YES IN No a DATE TO BE COMPLETED:FEBRUARY OR MARCH, 1 9 9 8 ❑ PUBLIC ® PRIVATE 17 ENTER THE INFORMATION BELOW FOR ANY COMMUNITY CARE OR HEALTH FACILITY OWNED OR OPERATED BY APPLICANTS.REFER TO INSTRUCTIONS A FACILITY N NErr NUMBER LICENSING AGENCY NAME B // iB APPLICANT(SyLICENSEE(S)RESPONSIBILITIES: A. W ADDITION TO COMPLYING WITH THE HEALTHAND SAFETY CODES AND REGULATIONS APPLICABLE TO LICENSING AND FIRE SAFETY ME UNDERSTAND THAT THERE MAY BE OTHER STATE,FEDERAL ANDVOR LOCAL LAWS.WHICH ARE NOT ENFORCED BY THIS AGENCY, THAT MAY NEED TO BE MET SUCH AS:ZONING,BUILDING,SANITATION AND LABOR REQUIREMENTS. S. VWEHAVE READAND UNDERSTAND THE STATUTESAND REGULATIONS WH/CH)PERIAIN TO MY/OUR LICENSING CATEGORYPRIOR TO THE ISSUANCE OR RENEWAL OFMY/OUR LICENSE. C. VINE SHALL ENSURE THATAT THE TIME OFEMPLOYMENTOR FIRSTDAY IN THE FACILIFYALL PERSONS SUBJECT TO FINGERPRHNTREGUIREMENTS SHALL BE FINGERPRINTEDAND COMPLETE AN AFFIDAVIT ON PRIOR CRIMINAL RECORD HISTORY.FINGERPRINTS SHALL BE SUBMITTED TO THE DEPARTMENT OF JUSTICE AS REOUIRED. D. IF VWE OPERATE A FACILITY WHICH PROVIDES CARE AND SUPERVISION TO CHILDREN. NYE SHALL ENSURE THATA CHILDABUSE INDEX CHECKFORM FOR EACH PERSON SUBJECT TO FINGERPRINT REQUIREMENTS IS SUSMITTEO TO THE DEPARTMENT OF JUSTICE AS REOUIRED. E VINE SHALL NOTIFY THE LICENSING AGENCY IMMEDIATELY IFA PERSON,SUBJECT TO FINGERPRINTING REOUIREMENTS.IS CONVICTED OFA CRIME AFTER EMPLOYMENT F. YWE SHALL OBTAW APPROVAL FROM THE LICENSING AGENCY PRIOR TO MAKING ANY CHANGE(S)THATAFFECT THE TERMS OF THE LICENSE, 19. VWE UNDERSTAND THATVWEHAVE THE RIGHT TOAPPEAL ANYDECISK)NREGARDING THE DISPOSIFIONOF THIS APPLICATION. A. VINE DECLARE UNDERPENALTY OFPERJURY THAT THE STATEMENTS ON THIS APPLICATION ANCON THE ACCOMPANYING ATTACHMENTS ARE CORRECT TO THE BEST OFMYIOUR KNOWLEDGE. SIGNED e-<, ,TLP ADMINISTRATOR COUNI"IMERESIGNEDSAN JOAQUIN DATETIO 9 9Y SIGNED Q� L"_nnE PARTNER cnury WHERE&ONED N4_1)IkILAN- DATE 10/9/97 uc xo6l�l