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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700883
Report Date: 09/26/2024
Date Signed: 09/26/2024 10:59:50 AM

Document Has Been Signed on 09/26/2024 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DAWSON'S LODGEFACILITY NUMBER:
342700883
ADMINISTRATOR/
DIRECTOR:		DAWSON-LACY, VERONICA L.FACILITY TYPE:
740
ADDRESS:5650 MARTIN LUTHER KING JR BLVTELEPHONE:
(916) 421-0233
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY: 12CENSUS: 7DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:26 AM
MET WITH:Veronica Dawson TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 09/26/2024 at 8:26 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with administrator Veronica Dawson. LPA explained the purpose of the visit. The current census is 7 with 1 facility staff.

This facility is a single story building licensed to serve twelve (12) ambulatory residents only. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting.

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed knifes kept and made inaccessible to residents in care. Hot water temperature was measured at 113.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and hallway of the facility. The fire extinguisher was last serviced on 08/19/2024. LPA observed the facility has a has a public telephone in the dining room. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. The first aid kit was checked and contained all of the required components. LPA requested resident and staff files for review. LPA reviewed 5 out of 7 resident files and 1 staff file, and they were complete.

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809 report were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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