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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057001380
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:10:11 AM

Document Has Been Signed on 03/21/2022 11:10 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:WATCH-GOLDSTRIKEFACILITY NUMBER:
057001380
ADMINISTRATOR:CHRISTINA GARIBAYFACILITY TYPE:
735
ADDRESS:342 GOLDSTRIKE ROADTELEPHONE:
(209) 754-3773
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 12CENSUS: 6DATE:
03/21/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cynthia Reyes, Residential Assistant IITIME COMPLETED:
11:25 AM
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On 03/21/2022 at 9:45am, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Cynthia Reyes, Residential Assistant II and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 12 clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, backyard and front yard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom were measured at 110 and 111.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day non-perishable and 2-day perishable foods.

LPA observed sprinkler system throughout the facility. Carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on March 11, 2022. Mitigation observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 02/08/2022. LPA reviewed 3 client files and 2 staff records.

LPA requested updated Emergency Disaster Plan be submitted to CCLD by 03/25/2022.

No deficiencies cited during inspection.

Exit interview conducted with Residential Assistant II and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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