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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700700
Report Date: 09/30/2021
Date Signed: 09/30/2021 03:39:19 PM

Document Has Been Signed on 09/30/2021 03:39 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:JENSEN HOME, THEFACILITY NUMBER:
392700700
ADMINISTRATOR:ROSSELL-JENSEN, SHERRIFACILITY TYPE:
735
ADDRESS:20560 N DAVIS RD.TELEPHONE:
(916) 247-6264
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 6CENSUS: 6DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Sherri Rossell Jensen, Administrator TIME COMPLETED:
10:45 AM
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On 09/30/2021 at 8:40am, Licensing Program Analyst (LPA) T. White spoke with Administrator, Sherri Rossell-Jensen regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:35 am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109.4 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishable foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on June 02, 2021. Emergency Disaster Plan was last posted on 09/02/2021. Mitigation Plan observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 09/01/2021.

The following forms to be updated and submitted to CCLD by 10/08/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
No deficiencies cited during inspection. Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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