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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701391
Report Date: 07/26/2024
Date Signed: 07/26/2024 10:53:02 AM

Document Has Been Signed on 07/26/2024 10:53 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:DELOSREYES RESIDENTIAL FACILITYFACILITY NUMBER:
342701391
ADMINISTRATOR/
DIRECTOR:		DELOSREYES, LEILANIFACILITY TYPE:
735
ADDRESS:8569 VINTAGE PARK DRIVETELEPHONE:
(916) 709-3272
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Leilani DelosreyesTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 0726/24 at 9:29 AM, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived at Delosreyes Residential Facility for the purpose of conducting a Change of Ownership (CHOW) pre-licensing inspection of the facility to ensure compliance with Title 22 regulations. LPAs met with Licensee/Administrator Florenda Tumamao and Leilani Delosreyes and together conducted a tour of the home. The census is 4 with 2 facility staff.

Facility has a fire clearance for 2 ambulatory and 2 non-ambulatory clients. Ambulatory clients are to reside in bedrooms #2 and #4. Non-ambulatory clients are to reside in bedrooms #1 and #3. Administrator, Leilani will be the Administrator of this facility. LPAs evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living room, dining room and outdoor areas. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. Client bedrooms were toured, and furniture and furnishings were observed to be sufficient and able to meet the needs of the clients.


LPAs measured the water temperature, temperature measured at 105.3 degrees Fahrenheit which meets the 105-to-120-degree Fahrenheit. The facility temperature observed at 73 degrees. The facility has a public telephone and has an area for activities. LPAs observed sufficient seven-day non-perishable and two-day perishable food supplies. The facility smoke detectors and carbon detectors were observed to be in good condition. The fire extinguisher was last service on 07/22/2024. First aid kit was checked and is complete. LPA observed centrally stored medications secure from clients.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. The applicant has passed the pre-licensing. LPA Lee will email CAB analyst for final approval. Component III Orientation was completed at this time with the Applicant. 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: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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