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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700332
Report Date: 02/09/2021
Date Signed: 02/10/2021 07:07:49 AM

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:A PLACE CALLED HOME IIFACILITY NUMBER:
392700332
ADMINISTRATOR:SIMONE A PIERRE JEROMEFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(209) 986-3949
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 8DATE:
02/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lesley Pinola, LicenseeTIME COMPLETED:
11:40 PM
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Licensing Program Analyst Bruce Jacobs conducted a Health and Safety inspection of the facility regarding concerns about financial issues. LPA met with Care staff Natalie and then with Licensee Lesley Pinola and explained the purpose of the visit. The facility currently has 8 residents, of which 4 are on hospice and the facility also cares for residents with dementia. At the time LPA arrived, there were 3 caregivers and a hospice worker.

LPA checked the food supplies and determined the facility had adequate supplies of food. Facility also had sufficient supplies of medications. LPA asked learned of no disruptions in utility services at he care home. Interviews with care staff and residents did not disclose any shortages or interruptions in food services or food delivery to the facility.

The facility was clean, safe and sanitary upon inspection. LPA determined that the staffing levels appear to be adequate to meet the needs of the residents and no staffing or care deficiencies were identified on this visit. LPA learned of no disruptions to payroll or other services. LPA spoke to two residents who stated that they were doing fine at the facility and reported no concerns.

No Deficiencies were identified or cited on this Health and Safety check.

Contents of this inspection and report discussed with Licensee and copy of report given to Licensee.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021
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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