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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700320
Report Date: 02/07/2025
Date Signed: 02/10/2025 08:21:54 AM

Document Has Been Signed on 02/10/2025 08:21 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:
02/07/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:PIAZZA, KATHYTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 02/07/2025 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. Robert Fernandez from Valley mountain regional was informed of the room switch. 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. Licensee states all required materials from the 1st rented room will be moved into the new space by 02/10/2025.

The LPA Lewis toured the facility with Kathy Piazza on 02/07/2025.

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: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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