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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700067
Report Date: 06/21/2021
Date Signed: 06/22/2021 10:26:57 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:HOSPITALITY HOUSEFACILITY NUMBER:
342700067
ADMINISTRATOR:SONYA SMITHFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 48DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Sonya SmithTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA’s) Sarah Hurt and Jason Lund arrived unannounced to conduct a Required – 1 Year inspection. . LPA’s met with Sonya Smith, Administrator and stated the purpose of today’s visit. LPA’s were allowed entry into the facility that is licensed to serve a total capacity of 48 residents. Facility has an approved hospice waiver for 15.

LPA’s observed residents during this visit. LPA's toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA's observed the facility conducts fire and disaster drills quarterly and annually.

. LPA’s observed 2 day perishables, and 7 day non-perishables during this visit.


LPA's observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and pull alarm system in the facility.

LPA's observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

An exit interview was conducted and a copy of this report was given to administrator.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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