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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700320
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:33:13 PM

Document Has Been Signed on 07/18/2024 12:33 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:VILLAGE: ADULT DEVELOPMENTAL AND COMMUNITY CT, THEFACILITY NUMBER:
392700320
ADMINISTRATOR/
DIRECTOR:
PIAZZA, KATHYFACILITY TYPE:
775
ADDRESS:25 E PINE STTELEPHONE:
(209) 712-0903
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 15CENSUS: 15DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Kathy PiazzaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 07/18/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Kathy Piazza and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for 12 non-ambulatory and 3 ambulatory clients

The LPA Martinez toured the facility with Kathy Piazza on 07/18/2024 at 12:00 PM.

LPA Martinez reviewed 5 client files and 5 staff files, which were maintained. The facility has a first aid kit, and fire extinguishers are in good repair. The facility bathroom, common areas, and kitchen were sanitary and furnished. LPA Martinez observed required posting posted throughout the facility. The facility temperature measured at 77 degrees, and water temperature measured at 105 degrees.

As a result of this this annual inspection visit, there were no deficiencies cited, An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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