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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700883
Report Date: 09/11/2020
Date Signed: 09/11/2020 04:29:21 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:DAWSON'S LODGEFACILITY NUMBER:
342700883
ADMINISTRATOR:DAWSON-LACY, VERONICA L.FACILITY TYPE:
740
ADDRESS:5650 MARTIN LUTHER KING JR BLVTELEPHONE:
(916) 421-0233
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:12CENSUS: 10DATE:
09/11/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Veronica Dawson-Lacy, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood contacted Administrator Veronica Dawson-Lacy via telephone to conduct a virtual inspection of the facility. The visit was conducted via telephone due to COVID-19 and precautionary measures. Applicant holds current administrator certificate #6049136740 exp. 10/7/20. There are currently 10 residents residing in the care home.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six bedrooms and four bathrooms for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 110 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. LPAs observed at least a 2-day perishable and 7-day nonperishable food supply on hand. LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents.

LPAs observed the perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards. Smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPAs reviewed two resident files and two staff files.

Pre-licensing passed and Component III completed. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPAs will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of this report shall be submitted to CCLD within 10 days of receipt of this report. Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020
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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