<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000731
Report Date: 04/11/2022
Date Signed: 04/11/2022 11:02:39 AM

Document Has Been Signed on 04/11/2022 11:02 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:DOSTY'S PRIVATE IN CARE SERVICE IIIFACILITY NUMBER:
347000731
ADMINISTRATOR:CAROLYN J. DOSTYFACILITY TYPE:
735
ADDRESS:2041 50TH AVENUETELEPHONE:
(916) 399-0408
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 4DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:CAROLYN DOSTY - ADMINISTRATORTIME COMPLETED:
11:02 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of the visit. Administrator Certification #6022970735 expires on 12/21/2022. The facility is licensed for 6 ambulatory clients. Age range 18 through 59 years. There are currently 4 clients.

LPA toured the facility with Administrator. LPA inspected the physical plant including but not limited to the common areas, kitchen, dining area, resident bedrooms; resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were properly maintained. The hot water measured 110.7*F which is within the required range of 105-120*F. The temperature inside the facility measured at 74 degrees Fahrenheit which is within the required range of 68-85*F. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher expires 8/25/22 and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

The facility mitigation plan was submitted to CCLD, and it was approved on 5/7/2021. Facility has routine symptom screening checks for clients, staff, and visitors. The facility has a symptom check binder for staff, clients, and care staff. Hand Hygiene procedures have been implemented. Facility had COVID-19 posters throughout the facility, and the facility has implemented COVID-19 mitigation plan.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview conducted with Administrator and copy of report left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1