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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700067
Report Date: 02/03/2022
Date Signed: 02/03/2022 01:07:30 PM

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:HOSPITALITY HOUSEFACILITY NUMBER:
342700067
ADMINISTRATOR:LORRAINE PADILLAFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 51DATE:
02/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Sabrina Duarte - Resident Care DirectorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Case Management Incident Visit. LPA met with Resident Care Director Sabrina Duarte and discussed purpose of visit. Facility has positive COVID-19 residents and staff, therefore LPA will only be in general office area on today's date. LPA discussed a solution for resident (R1) regarding the thirty eviction notice which will need to be served after Community Care Licensing reviews the notice.

No Deficiencies are being cited per Per California Code of Regulations, Title 22

Exit interview with Resident Care Director and copy of report provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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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