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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701237
Report Date: 04/19/2023
Date Signed: 04/19/2023 11:26:31 AM

Document Has Been Signed on 04/19/2023 11:26 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JOHN AND IVY RESIDENTIAL CAREFACILITY NUMBER:
342701237
ADMINISTRATOR:LOMBOY, IVY LOU MANIQUIZFACILITY TYPE:
735
ADDRESS:4159 WESTPORTER DR.TELEPHONE:
(916) 330-7692
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 4CENSUS: 0DATE:
04/19/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:John and Ivy LomboyTIME COMPLETED:
12:00 PM
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On 4/19/23 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at John and Ivy Residential Care for the purpose of conducting a required pre-licensing inspection. LPA met with Licensees, John and Ivy Lomboy and together conducted a tour of the home. the home is a single story home located in a residential neighborhood. The home is equipped with four single occupancy bedrooms with bedroom #4 identified as the non-ambulatory bedroom. The facility is equipped with two bathrooms, one in the hallway and one in bedroom #4.

LPA and Licensees evaluated the physical plant to ensure the health and safety of future residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 113.5 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications and sharp objects secure from residents.

Per California Code of Regulations, Title 22 there were no deficiencies observed today's inspection. This facility has met all requirements to be licensed. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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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