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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920130
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:24:30 PM

Document Has Been Signed on 09/04/2024 02:24 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VILLA SIERRA LODGE - SPENLOWFACILITY NUMBER:
345920130
ADMINISTRATOR/
DIRECTOR:		MAGPUSAO, LUALHATIFACILITY TYPE:
735
ADDRESS:9051 WINDING OAK DRIVETELEPHONE:
(831) 869-2201
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 4CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Michael Magpusao, Acting AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the care home unannounced on 9/4/24 to conduct a post licensing visit.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations and there is currently four (4) residents in care. There are four (4) bedrooms and two (2) bathrooms for resident use. LPAs observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPAs observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPAs observed the backyard and perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. LPAs reviewed four (4) resident files and one (1) staff file. Facility has a current copy of certificate of liability insurance and LPAs requested a copy.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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