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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700320
Report Date: 06/20/2023
Date Signed: 06/22/2023 01:35:37 PM

Document Has Been Signed on 06/22/2023 01:35 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 AC/SC, 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: 12DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shawnda Lopez, Program ManagerTIME COMPLETED:
04:30 PM
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On 06/20/23, Licensing Program Analyst(LPA) Renee Campbell arrived at Village Day Program and met with Program Manager Shawnda Lopez. The facility clients had left for the day and the Program Manager was the only remaining staff left. Shawnda greeted LPA Campbell at the door. LPA observed that the entrance lead into the main common area.

There was a seating area with a couch, blankets and coffee table. The non-ambulatory sensory area had a mat that was cleaned daily where residents could stretch.. There was a sensory room with a floor covered in mats. There were projected images and a bubble machine with string lights that could be held along with a seating area. There was one bathroom on the premises and the hot water temperature was measured at 109 degrees Fahrenheit.

The changing/cubby area was mainly used as storage for client belongings with coat hooks and soft cubby holes. The Kitchen area contained snacks for the residents, first aid box, coffee supplies and emergency food supplies for sheltering in place. Cleaning supplies and a knife were locked in a cabinet with keys that Shawnda kept with her. The facilities office was used by the Administrator Kathy Piazza who had been ill and was at home. The smoke and carbon monoxide detector are linked and will contact the Lodi Fire Department automatically when activated and could not be tested. However the fire drill log shows that monthly drills are done was last completed 06/11/23.

LPA Campbell reviewed 2 out of 3 staff files and 2 out of 12 client files. No deficiencies were cited.
Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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