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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390313117
Report Date: 05/24/2024
Date Signed: 05/24/2024 10:10:03 AM

Document Has Been Signed on 05/24/2024 10:10 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:LODI MEMORIAL HOSPITAL ADULT DAY SERVICES CENTERFACILITY NUMBER:
390313117
ADMINISTRATOR/
DIRECTOR:
TERESA WHITMIREFACILITY TYPE:
775
ADDRESS:125 SOUTH HUTCHINS, SUITE FTELEPHONE:
(209) 369-4443
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 30CENSUS: 30DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Teresa Whitmire and Karla FuentesTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 05/24/2024 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Teresa Fuentes and Karla Barba and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining are; resident bathrooms, laundry area, and activity area, of the facility to ensure compliance with Title 22 regulations.

Administrator holds current. The facility is licensed for 30 non-ambulatory clients. There are currently 30 clients who attend this day program.

The LPA Martinez toured the facility with Teresa Whitmire on 05/24/2024 at 9:45 AM.

LPA Martinez reviewed 10 client files and 5 staff files, which all files were maintained. The facility has an infection control plan, natural disaster plan, and fire drill log. The facility has a locked medication room, and Medication Administrations records were maintained. The facility has a first aid kit, and the last fire drill was on 05/08/2024. The fire extinguishers are in good repair. The facility kitchen, common areas, laundry area, and bathrooms were furnished and sanitary.



Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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