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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701238
Report Date: 09/01/2023
Date Signed: 09/01/2023 12:53:39 PM

Document Has Been Signed on 09/01/2023 12:53 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:STAYPOINT RESIDENTIALFACILITY NUMBER:
342701238
ADMINISTRATOR:OGENAH, OGIATOR MICHEALFACILITY TYPE:
735
ADDRESS:167 DANNY DRTELEPHONE:
(408) 373-7750
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 6CENSUS: 6DATE:
09/01/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Patrick OfoseTIME COMPLETED:
01:00 PM
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On 9/1//23 at approximately 10:10am Licensing Program Analyst (LPA) Jennifer Fain arrived at the facility unannounced to conduct a post licensing inspection. LPA met with Licensee Patrick Ofose and explained the reason for the visit. The facility is licensed for six (6) residents and currently has six (6) residents in care.

LPA observed residents relaxing in the living room, watching tv in the family room, outside on the patio and eating lunch. The lunch menu consisted of pizza, pudding, and coffee. LPA toured the facility, including but not limited to: the common living spaces, residents bedrooms; bathrooms, kitchen, staff rooms, garage and backyard. Resident's bedrooms had personal items decorating the space. Hot water temperature measures at 118 degrees F in resident bathroom. Medications are kept locked and inaccessible to residents. Food supply was adequate for 2-day perishable and 7-day non-perishable. Smoke and carbon monoxide detectors were present throughout the facility and in working order, fire extinguishers were serviced 8/10/23. Facility keeps a log of monthly fire drills. First aid kit was found to be complete. The facility has the required signage.

LPA reviewed 2 of 3 staff files and 6 of 6 residents files. Technical Assistance (TA) was provided regarding required file contents for both staff and resident files (check lists provided), documentation for P&I monies, updating LIC610D and LIC500. Licensee will send updated LIC500 and LIC610D to LPA at jennifer.fain@dss.ca.gov by 9/8/23. Licensee has requested TSP for staff and resident files.


Licensee will send new facility sketch to obtain fire clearance for a room change from resident space to staff quarters.

Pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code no deficiencies were cited. An exit interview was conducted and a copy of this report was provided to Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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