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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700298
Report Date: 06/06/2022
Date Signed: 06/28/2022 10:50:52 AM

Document Has Been Signed on 06/28/2022 10:50 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:
06/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Joseph Cruz and Aquilla CruzTIME COMPLETED:
02:00 PM
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LPA Albert Johnson arrived at the care home today and met with Staff to conduct a plan of correction visit in relation to a citation issued during case management visit on 4/12/22.

Citation issued : Criminal Record Clearance, 85065 Personnel Requirements and Health Related Services.

Licensee was to submit a staffing schedule ensuring adequate coverage to prevent lack of supervision, the facility was to develop a procedure to follow when staff observe that any resident is in need of a medical assessment from a medical professional to ensure that medical attention is provided in a timely manner and all staff will be cleared prior to working or volunteering.

These action items were completed and the facility is in compliance with the required plan of corrections

Exit Interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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