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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700320
Report Date: 06/22/2022
Date Signed: 06/24/2022 07:41:17 AM

Document Has Been Signed on 06/24/2022 07:41 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:VILLAGE: ADULT DEVELOPMENTAL AND COMMUNITY CT, THEFACILITY NUMBER:
392700320
ADMINISTRATOR:PIAZZA, KATHYFACILITY TYPE:
775
ADDRESS:25 E PINE STTELEPHONE:
(209) 712-0903
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 15CENSUS: 8DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kathy Piazza, Executive DirectorTIME COMPLETED:
01:45 PM
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On 06/22/2022 at 11:45 AM, Licensing Program Analyst (LPA) T. White arrived unannounced on this day for the purpose of conducting a Required 1 year inspection. LPA met with Executive Director (ED) Kathy Piazza and explained the purpose of the visit.

Present at the facility on this day was 8 client and 4 staff along with the Executive Director.

At 12:15 PM, LPA toured the facility with ED Piazza and inspected food services. There were snacks available for clients. Clients provide own lunches but facility does have plan in place for meals if needed. LPA observed clients eating lunch. LPA observed facility does not manage medications. LPA inspected changing area, which was clean and odor free. Bathroom was inspected. Hand washing areas were clean and in good repair. Temperature measured at 75 degrees Fahrenheit. Hot water temperature measured at 108.7 degrees F. in clients shared bathroom. Fire Drill last conducted on 05/03/2022. LPA observed smoke detector and carbon monoxide interconnected with the fire department.
LPA reviewed 3 client files and 3 staff record files.

No deficiencies cited during inspection. Exit interview conducted with Executive Director and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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