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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700883
Report Date: 10/24/2023
Date Signed: 10/24/2023 12:32:30 PM


Document Has Been Signed on 10/24/2023 12:32 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 9DATE:
10/24/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Veronica L. Dawson-LacyTIME COMPLETED:
12:50 PM
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Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 10/24/2023 at 10:45 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with administrator, Veronica Dawson and explained the purpose of the visit. The purpose of this visit is to follow-up on plan of corrections that were due on 10/15//2023. During today's visit, LPA Lee reviewed residents and staff files to ensure all deficiencies previously cited have been corrected.

Based upon this inspection, the LPAs observed the following:
I. Deficiency cited under Title 22 Regulation 87412(a) has been cleared. Licensee complied with the terms of the POC by POC due date 10/15/2023. A POC letter was generated and provided to the licensee.

2. Deficiency cited under Title 22 Regulation 87506(b) has been cleared. Licensee complied with the terms of the POC by POC due date 10/15/2023. A POC letter was generated and provided to the licensee.

3. Deficiency cited under Title 22 Regulation 87465(d) has not been cleared. Licensee will complied with the terms of the POC by POC due date 10/05/2023.

An exit interview was held, and a copy of this report, LIC 809 was given to the facility at the end of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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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