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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700250
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:05:36 PM

Document Has Been Signed on 06/23/2021 03:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OPTIMUM SENIOR CARE HOMEFACILITY NUMBER:
392700250
ADMINISTRATOR:PRISCILLA QUITEVISFACILITY TYPE:
740
ADDRESS:209 N SCHOOL STREETTELEPHONE:
(209) 298-7258
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 24CENSUS: DATE:
06/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Priscilla Quitevis, AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst Bruce Jacobs met with Facility Administrator Priscilla Quitevis to discuss a recent incident report the facility submitted to the department. The report documented a resident who left the facility and did not return at a designed time. After the resident failed to return for dinner, a Police reporter was filed. The resident did return the following day without incident. The resident's file was reviews and the Physician's report (LIC 602) stated the resident is capable of leaving the facility unassisted. The residents file was reviewed and a copy of the physician's report was received.

No deficients are issued on this case management report.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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