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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700700
Report Date: 10/10/2023
Date Signed: 10/10/2023 09:46:00 AM

Document Has Been Signed on 10/10/2023 09:46 AM - 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:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Sherri Rossell-Jensen - AdministratorTIME COMPLETED:
10:15 AM
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required annual inspection visit. LPA met with administrator and stated the purpose of today’s visit.
 
LPA and administrator inspected and toured physical plant inside and outside to ensure the safety of the residents and compliance with Title 22 regulations.
 
LPA observed the temperature inside the facility was measured at 75 *F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 112.3 *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 observed the fire alarm, fire extinguisher(s) were last inspected on May 25, 2023, smoke and carbon monoxide detectors, central heating, and air in the facility. A first aid kit and an emergency supply of food/water was observed. Sharps were observed to be locked up.

LPA reviewed three staff and three resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.
 
LPA received the following updated documentation on today's date: LIC 308 Designation of administrator and copy of surety bond.

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 

Exit interview held with Administrator. A report and LIC 811 (Confidential Names) was left at the facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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