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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700320
Report Date: 11/12/2024
Date Signed: 11/12/2024 10:26:04 AM

Document Has Been Signed on 11/12/2024 10:26 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
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:
11/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 PM
MET WITH:Kathy Piazza TIME VISIT/
INSPECTION COMPLETED:
10:45 PM
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On 11/12/2024 Licensing Program Analyst (LPA) Kesha Lewis made an announced visit to this facility to conduct a case management visit. LPA LEWIS met with Kathy Piazza and explained the purpose of the visit. Also present at the visit was Robert Fernandez from Valley mountain regional and Building staff. LPA Lewis inspected the physical plant including but not limited to the bathrooms, 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. there is a water feature in the back courtyard and no staff that have water safety training so the licensee agrees to not use the back courtyard area. Licensee agrees to purchase a first aid kit and carbon monoxide detectors and placing cation hot water signs in the bathrooms before opening the day program on 11/13/2024.

The LPA Lewis toured the facility with Kathy Piazza on 11/12/2024.

Fire extinguishers are in good repair. The facility bathroom, common areas were sanitary and furnished. LPA Lewis observed required posting posted throughout the facility.The facility temperature measured at 77 degrees.

As a result of this this case management visit there were no deficiencies cited, An exit interview was conducted, and a copy of this report given.

Kesha.lewis@dss.ca.gov

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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