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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700743
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:57:53 AM

Document Has Been Signed on 12/13/2021 11:57 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:LA FAMILIA RESIDENCEFACILITY NUMBER:
392700743
ADMINISTRATOR:YEPIZ, GUADALUPE CRYSTALFACILITY TYPE:
735
ADDRESS:627 W TURNER ROADTELEPHONE:
(209) 310-2192
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 4DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Guadalupe Yepiz TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 12/13/2021. LPA met with Guadalupe Yepiz and explained the purpose of the visit. Guadalupe Yepiz is the Administrator and holds certificate #6040451735 that expires on 06/01/2022.

This facility is a single story building licensed to serve six (6) ambulatory residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (113) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 02/21/2021. Thermostat observed at (70) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed resident and staff roster. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

The following forms need updating and were collected on 12/13/2021:
LIC 308, LIC 500, LIC 610, LIC 9020, certificate of liability insurance, copy of administrator certificate
No deficiencies were found during today's visit. Exit interview held with Guadalupe Yepiz and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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