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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700238
Report Date: 09/16/2023
Date Signed: 09/16/2023 04:08:59 PM

Document Has Been Signed on 09/16/2023 04:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SEVEN STARS CARE HOMEFACILITY NUMBER:
342700238
ADMINISTRATOR:SARAH MIKAILFACILITY TYPE:
735
ADDRESS:1317 COFFEE VILLA DRIVETELEPHONE:
(209) 595-8534
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 4DATE:
09/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sarah Mikail TIME COMPLETED:
03:00 PM
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On 09/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator,Sarah Mikail and explained the purpose of the visit.

This facility is licensed to serve and accept up to 6 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 2 residents at this time. Census was currently at 4. Tour of the facility was conducted.
LPA reviewed 2 staff files and 2 resident files. All of which are current and up to date. The administrator has a current administrator certificate #6010139735 and expires on 10/08/2023.
Fire extinguisher located in the kitchen and office was serviced by Assured and is valid until 10/20/2023.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage units were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time.
LPA Pascua observed a locked centralized stored medication cabinet located in the living room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the garage was conducted. Additional storage for supplies and files were stored in cabinets. The Administrator office was identified in the garage.
A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair. A washer and dryer was identified in the back patio. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SEVEN STARS CARE HOME
FACILITY NUMBER: 342700238
VISIT DATE: 09/16/2023
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A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023
LIC809 (FAS) - (06/04)
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