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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700298
Report Date: 03/04/2025
Date Signed: 03/11/2025 07:14:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/11/2025 07:14 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DIZON VALLEY CARE HOMEFACILITY NUMBER:
392700298
ADMINISTRATOR/
DIRECTOR:		DIZON, LISSETFACILITY TYPE:
735
ADDRESS:2830 SAN ROCCO DRTELEPHONE:
(510) 435-7428
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 5DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mary Baldwin TIME VISIT/
INSPECTION COMPLETED:
02:15 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
On 03/11/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA Pascua met with Facility Designated Representative (FDR), Mary Baldwin and explained the purpose of the visit. This facility is licensed to served and accept up to 6 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 4I residents at this time.
Current census was

LPA reviewed 2 resident files. 2 out 2 resident files are complete and up to date. LPA reviewed 4 staff files. 4 out 4 staff files are complete and up to date. The Facility Designated Administrator has an active administrator certificate and expires on 10/26/2026.
Fire extinguisher located by the kitchen and upstairs closet appeared to have been annually inspected on 06/25/2024 by Fire Supply and Service Company.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage units were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Additional non-perishable food supply was identified in the pantry and garage.
LPA Pascua observed a locked centralized stored medication closet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the garage was conducted. Additional storage for supplies were stored in cabinets.
A tour of the laundry room was conducted. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIZON VALLEY CARE HOME
FACILITY NUMBER: 392700298
VISIT DATE: 03/04/2025
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
26
27
28
29
30
31
32
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.
A linen closet was located in the office and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.`
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610e.

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2