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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700626
Report Date: 05/25/2022
Date Signed: 05/31/2022 02:02:23 PM

Document Has Been Signed on 05/31/2022 02:02 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:NATIONAL SAN JOAQUINFACILITY NUMBER:
392700626
ADMINISTRATOR:VALERIE VOILFACILITY TYPE:
772
ADDRESS:401 SOUTH AIRPORT WAYTELEPHONE:
(916) 238-1619
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 14CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elizabeth SauersTIME COMPLETED:
01:30 PM
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Unannounced annual visit made out to this facility on 05/25/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua who were met by the facility Program Manager Elizabeth Sauers who was interviewed.
LPAs set up in a separate pod building in the rear of this facility.
Current census was 4 residents.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed for an adequate supply of plates, silverware, and other items intended for use by the residents.
Food supply was reviewed for an adequate supply of 2-day perishable and 7-day nonperishable food quantities at all times. LPAs observed several food storage units within this facility in the form of additional refrigerator and freezer units.
Medication room was toured. LPAs observed the use of a medication cart that was locked and made inaccessible to the residents at all times. This facility employed the use of an E-MAR system, Point Click Care, to dispense, manage, and document all medications for the residents at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 05/09/2022 by Armor Fire Extinguisher Company and in compliance at this time.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms (3) was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
A tour of the laundry area was conducted. It was learned that residents were scheduled on a weekly basis to wash and dry their own clothes with the assistance of facility staff if necessary. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: NATIONAL SAN JOAQUIN
FACILITY NUMBER: 392700626
VISIT DATE: 05/25/2022
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A tour of the common areas was conducted. Living area, dining area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the staff break room and separate restroom was conducted.
A tour of the exterior grounds was conducted.
Facility perimeter fence, side gates, and all exits were reviewed.

The following forms and documents were requested by LPAs 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: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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