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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390313117
Report Date: 04/14/2022
Date Signed: 04/29/2022 08:44:55 AM

Document Has Been Signed on 04/29/2022 08:44 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:LODI MEMORIAL HOSPITAL ADULT DAY SERVICES CENTERFACILITY NUMBER:
390313117
ADMINISTRATOR:TERESA WHITMIREFACILITY TYPE:
775
ADDRESS:125 SOUTH HUTCHINS, SUITE FTELEPHONE:
(209) 369-4443
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 30CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Theresa Whitmire, DirectorTIME COMPLETED:
11:00 AM
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On 04/14/2022 at 8:50 am Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year annual inspection. LPAs spoke with Director, Teresa Whitmire and explained the purpose of the visit. Director confirmed no staff or clients have experienced symptoms within the last 10 days and that all staff and clients have been vaccinated and received COVID booster shots.

LPAs toured physical plant inside and outside to ensure safety for the clients. LPAs observed all passageways clear and free of hazards. Hot water temperatures in clients shared bathrooms was measured at 110 degrees Fahrenheit. Bathroom stalls were appropriately supplied. LPAs observed medications locked and inaccessible to clients. This facility serves morning snacks and afternoon lunches. LPAs observed the kitchen was clean with an adequate food supply.

LPAs observed facility fire extinguisher last serviced on 12/06/2021. LPAs observed smoke detector is interconnected with the fire department. The carbon monoxide detector was successfully tested. This property is a city building. LPAs observed facility's approved mitigation plan. Fire Drill last conducted 04/05/2022. Emergency Disaster Plan last posted on 01/11/2022. LPAs reviewed 3 client files and 2 staff record files.

No deficiencies cited during inspection.

Exit interview conducted with Director and copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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