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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057001380
Report Date: 12/13/2022
Date Signed: 12/13/2022 02:51:41 PM

Document Has Been Signed on 12/13/2022 02:51 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:WATCH-GOLDSTRIKEFACILITY NUMBER:
057001380
ADMINISTRATOR:CHRISTINA GARIBAYFACILITY TYPE:
735
ADDRESS:342 GOLDSTRIKE ROADTELEPHONE:
(209) 754-3773
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 12CENSUS: 5DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Christina Garibay - AdministratorTIME COMPLETED:
11:30 AM
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility after COVID-19 assessment and temperature taken. Facility is licensed to serve a total capacity of 12 clients.

LPA and administrator 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. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 110.9 degree 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. Sprinkler system was in compliance. Carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on 3/11/2022 . Mitigation observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 11/8/2022.

LPA reviewed three (3) resident files and three (3) staff files. A review of staff records indicates that all facility staff & other individuals who require caregiver background checks are fingerprint cleared and to the facility. LPA verified staff training for staff file reviews and all 3 staff have current First Aid Certificates.

No deficiencies were observed from the California Code of Regulations, Title 22.

Exit interview conducted with Administrator and copy of report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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