<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700250
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:25:56 PM

Document Has Been Signed on 06/23/2021 04:25 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: 23DATE:
06/23/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Priscilla Quitevis, Facility AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Bruce Jacobs met with Facility Administrator Priscilla Quitevis to discuss the corrective actions required from the facility from an inspection completed on 5/28/212. The Facility Administrator replaced the carbon monoxide detector on 5/29/21. LPA tested the device and it was operational. Facility also provided in-service training on the requirements for all staff to properly wear a mask at all time. The facility provided proof that the corrective action for the citation had been completed. These deficiencies will be cleared. In addition, the facility provided proof that maintenance needed on doors and blinds had been completed and photos of actions completed obtained.

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)
Page: 1 of 1