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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700883
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:23:17 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: 11DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Administrator Veronica Dawson-LacyTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 09/21/2021. LPA met with staff Veronica Dawson-Lacy and explained the purpose of the visit. Veronica Dawson-Lacy is the Administrator and holds certificate #6049136740 that expires on 10/07/202.

This facility is a single story building licensed to serve twelve (12) ambulatory residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (108.5) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 07/11/2021. Thermostat observed at (78) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

The following forms need updating and submitted to CCLD by 09/27/20221:
LIC 610, Copy of liability insurance
LPA received copies of LIC 308, 500, Administrator Certificate during today's visit on 09/21/2021

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were found during today's visit on 09/21/2021. Exit interview held with Veronica Dawson-Lacy and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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