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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390313117
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:18:09 PM

Document Has Been Signed on 04/04/2023 03:18 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 AC/SC, 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: 30DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Terry Whimire, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Renee Campbell arrived unannounced to conduct an Annual Required visit on this date.

LPA inspected the facility, which included but not limited to the bathrooms, kitchen, living room and the outside area of the facility. LPAs observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 72 degrees Fahrenheit for clients in care. Food supply was stored and prepared in a healthful manner. Clients received snacks and a hot lunch. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. LPA reviewed 5 of 9 staff files and 5 of 30 client files. All staff members have a current first aid and CPR. First aid kit was checked and is complete and disaster drill is current.

The following most recent forms were provided during inspection and will be submitted to CCL.:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization

No deficiencies were cited during this inspection.

Exit interview conducted. Report provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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