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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032700845
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:35:58 PM

Document Has Been Signed on 07/16/2024 04:35 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SUNRIDGE PLACEFACILITY NUMBER:
032700845
ADMINISTRATOR/
DIRECTOR:
SIX, ZULLYFACILITY TYPE:
735
ADDRESS:14124 LUPE ROADTELEPHONE:
(209) 296-5574
CITY:PINE GROVESTATE: CAZIP CODE:
95665
CAPACITY: 4CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Zully SixTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required visit. LPA Valerio rang the door bell twice and contacted Administrator Zully Six. Administrator Zully stated she would arrive at the home between 2:40 - 3:15 PM. LPA Valerio was later met Administrator Zully.

LPA Valerio and Administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA Valerio observed the kitchen area, dinning room, and common area. Areas were observed to be clean, organized, and free from debris. The facility meets the food requirement of 7 days of non-perishables and 2 days of perishables. LPA observed the facility to have an emergency supply of food and supplies in the downstairs area. Resident bedrooms were observed to be clean and free from odors. Resident bathrooms were observed to be clean and fully stocked. Hot water was measured between the regulatory range of 105.0 - 120.0 degrees. The facility temperature was observed to be at a comfortable temperature for residents and staff. All sharps, toxins, and cleaning supplies were observed to be locked away and inaccessible to residents in care.

Residents were observed coming home from Day Program and work. Residents were observed playing video games, going on an outing with staff, and cleaning their room. Staff were observed talking to the residents, preparing dinner, and taking resident on an outing.

LPA Valerio reviewed 2 resident files and 2 staff files. Files were observed to be complete and up to date with current information. LPA Valerio requested the following annual documentation be sent to the Regional Office: LIC 500 Personnel Report, LIC 308, LIC 610D, and copy of surety bond

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of this report was provided to Administrator Zully Six.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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