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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700700
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:21:23 PM

Document Has Been Signed on 10/11/2022 03:21 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: 5DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sherri Rossell-JensenTIME COMPLETED:
03:30 PM
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 Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual inspection. LPA Valerio met with facility staff, and stated the purpose of today’s visit. Licensee arrived at the facility shortly after LPA.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. The infection control tool was completed during the visit. The facility has an Infection Control Plan and a Monkey Pox Infection Control Plan on file that meets department regulations.
 
LPA observed the temperature inside the facility was measured at 74 *F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 106.2 *F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA Valerio observed the fire alarm, fire extinguisher(s), smoke and carbon monoxide detectors, central heating, and air in the facility. Fire extinguishers were up to date with last check on 10/01/2022. A first aid kit and an emergency supply of food/water was observed. Sharps were observed to be locked up.
 
LPA requested the following documentation: LIC 500, LIC 308, LIC 610E, Administrator Certificate, Infection Control Plan - Monkey Pox

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited.  Exit interview held with Administrator Sherri, and a report was left at the facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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