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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701060
Report Date: 11/20/2023
Date Signed: 11/20/2023 12:10:03 PM


Document Has Been Signed on 11/20/2023 12:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
11/20/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Virginia YadaoTIME COMPLETED:
12:15 PM
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On 11-20-23 at 10:37am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. A previous attempted visit was conducted on 9-12-23. LPA met with the administrator Virginia Yadao and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 0. Licensee is currently awaiting vendorship from regional center. Facility has 4 bedrooms and 3 bathrooms for resident use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 70*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 6-22-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible. Medication storage area was observed to be locked and inaccessible. First aid kit was observed to have adequate supplies and accessible to staff. All staff noted on LIC 500 contained criminal background clearances. Facility’s surety bond is current and update to date per regulatory requirements. Facility has a current liability insurance in place. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Virginia Yadao
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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