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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312975
Report Date: 06/19/2020
Date Signed: 06/19/2020 09:31:27 AM

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:DAWSON LODGEFACILITY NUMBER:
340312975
ADMINISTRATOR:DAWSON, MINNIE L.FACILITY TYPE:
740
ADDRESS:5650 MARTIN LUTHER KING BLVDTELEPHONE:
(916) 421-0233
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:12CENSUS: 11DATE:
06/19/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Veronica Dawson-Lacy AdministratorTIME COMPLETED:
09:15 AM
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At 9:00 AM, Licensing Program Analyst (LPA) Michael Hood conducted a tele-visit with Administrator Veronica Dawson-Lacy due to current COVID-19 precautionary measures. LPA observed residents throughout the facility. Administrator stated the residents are doing well.

Administrator guided LPA through interior and exterior of the facility, including the common areas, bathrooms, laundry room, kitchen, garage and office. LPA observed the facility to be clean and in good repair. LPA observed at least a two-day perishable and seven-day non-perishable food supply on hand. LPA observed medications and toxins to be locked away and inaccessible to residents. Administrator observed gloves, masks, hand sanitizer, and sufficient toilet paper on site.

LPA inquired about potential COVID-19 cases at the facility per assignment from LPM. Administrator confirmed the facility does not have any COVID-19 positive cases.

No deficiencies were cited as a result of today's tele-visit. Exit interview was conducted with Administrator via telephone and a copy of this report will be provided to the facility via email. This facility shall sign and return a copy of the report to CCL and print a copy to be retained by the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 243-4743
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020
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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