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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700603
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:35:31 PM

Document Has Been Signed on 07/07/2022 04:35 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:AUSTIN ROAD HOMEFACILITY NUMBER:
392700603
ADMINISTRATOR:WARREN, KATHYFACILITY TYPE:
735
ADDRESS:16590 S AUSTIN RDTELEPHONE:
(209) 823-6061
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Melinda WombleTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Arielle Pascua and Jason Lund conducted an unannounced Required-1 Year Inspection Visit. LPAs met with Facility Designated Administrator, Melinda Womble and stated the purpose of today’s visit. Current census was 4 residents.

This facility is licensed to serve and accept up to 6 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 4F residents at this time.
Tour of the facility was conducted.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage units were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time.
Medication cabinets, located in front area, was reviewed. First aid kit was present and observed to contain all of the required components at this time.

Fire extinguishers were observed to have been annually inspected on 01/18/2022 by the local fire equipment company and found to be in compliance at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and in compliance at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in laundry room, was reviewed and observed to be in compliance at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits was conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
VISIT DATE: 07/07/2022
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Laundry room was toured. Cleaning agents and detergents were observed to be locked and made inaccessible to the residents at this time.

The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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