185002765-8-10-2023-59-AS-SBEN-CUKW38-20230810165530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 185002765
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:55:34 PM

Document Has Been Signed on 08/10/2023 04:55 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ZAMORA RESIDENCE II		FACILITY NUMBER:	185002765
ADMINISTRATOR:	MOTTS, ALICIA		FACILITY TYPE:	735
ADDRESS:	116 SOUTH MESA		TELEPHONE:	(530) 257-2956
CITY:	SUSANVILLE	STATE: CA	ZIP CODE:	96130
CAPACITY: 6		CENSUS: 4	DATE:	08/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Savannah Gorbet Administrator		TIME COMPLETED:	04:55 PM

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08/10/2023 at 03:00 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Annual yearly Required inspection. LPA met with Savannah Gorbet Administrator and explained the purpose of the visit.

LPA Benson and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked closet.

Administrator certificate is current. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 07-06-23, the facility has been conducting drills every month.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and a copy of report was provided to Savannah Gorbet Administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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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