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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701060
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:18:57 PM


Document Has Been Signed on 10/19/2022 03:18 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:SV RESIDENTIAL FACILITY 2FACILITY NUMBER:
392701060
ADMINISTRATOR:YADAO, VIRGINIA ARRUBIOFACILITY TYPE:
740
ADDRESS:516 TULE SPRING STREETTELEPHONE:
(209) 915-9955
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:4CENSUS: 0DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Virginia YadaoTIME COMPLETED:
03:30 PM
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On 10/19/22 at 2:01pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Virginia Yadao and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed residential care facility for the elderly (RCFE) with a current census of 0. Facility has 4 bedrooms available for clients and located downstairs. Staffing quarters are located upstairs. Licensee is currently waiting for vendorship approval from regional center. Facility also has a dining area off the kitchen and a formal living room area for residents. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 6-16-22. Facility has an emergency food and water kit. All sharp objects a other dangerous items are locked and secured.
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with and a report was given to Administrator Virginia Yadao.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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