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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700461
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:04:46 PM

Document Has Been Signed on 10/10/2023 02:04 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:KIRSTEN COURT CARE HOMEFACILITY NUMBER:
392700461
ADMINISTRATOR:QURESHI, MUHAMMADFACILITY TYPE:
735
ADDRESS:2553 KIRSTEN COURTTELEPHONE:
(209) 224-1946
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 4CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Ali Qureshi & Ysenia MendozaTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 10/10/2023 at 12:38 PM. LPA Martinez met with Ali Qureshi & Ysenia Mendoza and stated the purpose of today’s 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.

Administrator holds current certificate and expires on 10/24/2024. The facility is licensed for four ambulatory clients. There are currently four clients who reside at this facility.

LPA Martinez toured the facility with Ali Qureshi & Ysenia Mendoza on 10/10/2023 at 1:20 PM.

LPA Martinez reviewed two employee and client files, and the files were maintained. In addition, LPA Martinez reviewed two medication files, and the files were maintained. The first aid kit is complete. The fire extinguishers, smoke detectors, and carbon detectors are in good repair. The emergency exit door is in good repair. The last fire drill was on October 1, 2023. The facility has a food and emergency kit, and has a natural disaster plan. The facility has an infection control plan. Also, the facility kitchen is sanitary, and has an adequate food supply. The laundry room is sanitary, and the appliances are in good repair. The facility water temperature measured at 105 degrees, and the facility temperature measured at 74 degrees. Clients bathrooms are sanitary. The facility has an area for activities, and the facility has a public telephone.

Based on this annual inspection on 10/10/2023, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was held, and a copy of this report was given at the end of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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