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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700250
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:41:21 PM

Document Has Been Signed on 04/12/2022 04:41 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: 22DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Priscilla Quipevis, AdministratorTIME COMPLETED:
04:00 PM
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On 04/12/2022 at 1:00 PM, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year annual inspection. LPAs met with Administrator, Priscilla Quipevis and explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 24 non-ambulatory residents, which 6 may be on hospice.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110 and 120 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

LPAs observed smoke detectors is interconnected with the fire department. Carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on December 13, 2021. LPAs observed completed mitigation plan. LPAs reviewed 5 resident files and 5 staff record files.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 004/22/2022:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan

No deficiencies cited during inspection.

Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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