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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700081
Report Date: 11/18/2021
Date Signed: 11/19/2021 07:51:20 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/19/2021 07:51 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:MICHELE'S FAMILY HOMEFACILITY NUMBER:
392700081
ADMINISTRATOR:ATKINS, MICHELEFACILITY TYPE:
735
ADDRESS:338 SPARROW LANETELEPHONE:
(209) 747-4639
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 2CENSUS: 2DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:ADMINISTRATOR - MICHELE ATKINSTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted a unannounced Required - 1 year Evaluation on 11/18/2021 attempted 10:00 am. LPA returned at 12:30 PM to complete the visit. LPA met with Administrator/Administrator (AD) Michele Atkins. Administrator's Certificate #6031560735 expires 7/27/2022.
LPA toured the interior and exterior of the facility with AD. The facility is a single story home. LPA observed food services. There was enough food on hand to meet the 2 day perishable and 7 day non-perishable requirement. Clients are Tube fed Gastrostomy-Jejunostomy. Medications were centrally stored and inaccessible to clients . LPA was able to confirm medications were being administered per physician's orders. Smoke detectors and carbon monoxide detectors ware observed operational. LPA measured hot water temperature which measured 113.1 degrees F. Fire extinguisher was observed mounted and charged, expires 04/26/2022. LPA discussed emergency preparedness with AD Atkins.
, wed 2 client files. Items reviewed but not limited to were IPP, Physician's report, TB test results, Personal Monies, and medications with no concerns noted. LPA reviewed staff files. Items reviewed but not limited to health screening, TB and CPR/First Aid training with no concerns noted.
The following documents needed to be submitted to licensing by January 11, 2022:
Admissions Policies and Procedures, Plan of Operation, Fire Clearance - Copy, Administrator Certificate, and Transportation Policies, and a copy of Surety Bond
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client Cash Resources
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed or cited today. Failure to correct cited deficiencies by the noted due date; civil penalties may be assessed.
Exit interview conducted. A copy of this report was left with Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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