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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700298
Report Date: 01/20/2022
Date Signed: 01/20/2022 11:42:59 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/20/2022 11:42 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:DIZON VALLEY CARE HOMEFACILITY NUMBER:
392700298
ADMINISTRATOR:DIZON, LISSETFACILITY TYPE:
735
ADDRESS:2830 SAN ROCCO DRTELEPHONE:
(510) 435-7428
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 4DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:M. BaldwinTIME COMPLETED:
11:45 AM
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icensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual/random visit on this date. LPA met with Mary Baldwin.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 110 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed to the facility. First aid kit was checked and is complete. Fire drill was conducted 11/15/2021.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed and cited during this visit.

Exit interview held and a report given at the conclusion of the visit
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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