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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700332
Report Date: 03/15/2021
Date Signed: 03/16/2021 11:47:57 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: 7DATE:
03/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Brandi VargasTIME COMPLETED:
02:30 PM
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Unannounced case management visit made out to this facility on 03/15/2021 by LPA Yang to conduct a health and wellness check on the facility and it's residents. LPA Yang was met by the facility designated Administrator, Brandi Vargas, who was in the process of submitting her documents for the change in Administrator at this time.
Current census was 7 residents.
It was learned that (6) of the (7) residents were under the care of hospice at this time. In addition, (1) resident was under the care of home health at this time.
A brief tour of the facility was conducted.
Living space and areas intended for resident use were toured.
Facility resident bedrooms were toured. Furniture and furnishings were reviewed and were observed to be in compliance at this time.
Facility resident restrooms were toured. Grab bars were observed to be present and in compliance at this time.
Kitchen area was toured. It was observed that lunch was in the process of being served to the residents at this time. Food supply for 2-day perishable and 7-day non perishable quantities were observed to be present and in compliance at this time.
It was observed that (4) of the residents were in the living area watching television. It was observed that (3) residents were in their respective bedrooms at the time of this visit. The residents were observed to be content with the staff and facility at this time.
Postings were observed to be present and visible for policies and procedures related to COVID 19 at this time. Disposable masks and cleaning agents were made available as you entered from the front door.

There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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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