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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700461
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:26:54 PM

Document Has Been Signed on 10/19/2022 12:26 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Edward Cueto - House ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with the house manager and explained the purpose of the visit. Administrator Certificate Expires 4/16/2023

LPA and house manager inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed adult residential facility with a current census of 4. Facility has 4 bedrooms and 2 bedrooms for client use. No obstructions to emergency exits. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 117.5*F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were inspected 10/01/22. Facility has an emergency food and water kit. Fire Drill conducted 9/2/22.

LPA reviewed 2 Staff and 2 Resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with house manager and a report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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