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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317173
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:09:53 PM

Document Has Been Signed on 08/09/2024 02:09 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:DOSTY'S PRIVATE INCARE SEVICES IIFACILITY NUMBER:
340317173
ADMINISTRATOR/
DIRECTOR:		JANAE D ROSSFACILITY TYPE:
735
ADDRESS:6924 SOUTH LAND PARK DRIVETELEPHONE:
(916) 399-8109
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 4DATE:
08/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Janae RossTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 8/9/24 at 12:30p to conduct a health and safety check on the residents who reside in the facility. LPA was met by Janae Ross, Administrator and stated the purpose of the visit. This Case Management visit is to ensure the safety of the residents as rodents and bed bugs were reported to Community Care Licensing (CCL) and that all residents were relocated temporarily. LPA and Administrator toured the physical plant inside the home. LPA observed the facility has prepared two areas of large items to be discarded. The facility has scheduled a large pick up with the city. LPA observed the beds of Resident 1 (R1) and (R2) and the enclosed area that holds the water heater. The Administrator removed the spotted mattress cover from the bed of R1. Under the mattress cover, the LPA and Administrator did not observe any areas that were reddish brown that would indicate bed bugs. LPA and Administrator also observed that the wiring in the floor of the enclosed water heater had a hole in it.

LPA also visited the site where the residents were relocated and found the residents to be very vocal, ambulatory, and pleased with their accommodations. During the visit, the residents were reviewing personal items that they would like to be transported to this new location.


At this time, there does not seem to be a health and safety concern.

Community Care Licensing will return on a later date to ensure the safety of the residents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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