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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701060
Report Date: 09/24/2024
Date Signed: 09/24/2024 02:39:32 PM


Document Has Been Signed on 09/24/2024 02:39 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: 1DATE:
09/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Viginia YadaoTIME COMPLETED:
02:45 PM
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On 9/24/2024 at 2:10pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding facility's new client admission on 9/23/2024. LPA met with Administrator Virginia Yadao and explained the purpose of the visit. LPA conducted a facility observation and brief interview with resident1 (R1) and Administrator. LPA observed facility to be clean and sanitary with no foul odors. LPA observed facility to be free from stains on floor and walls. Facility has a total of 7 bedrooms of which 4 are for resident use. Facility has three 3 bathrooms for resident use. LPA further observed R1's medications in place, locked and secured. R1 was admitted to facility for a 14-day emergency respite. All files for R1 were in electronic format on Administrator's computer. All R1's personal belongings were in place in R1's room.

Based on interview conducted with R1, R1 is adjusting adequately to surroundings and is continuing to attend day program as scheduled. Facility staff are assisting R1 with appointments and transportation as necessary. Facility has adequate food supply at this time. No obstructions to fire exits noted. Smoke and carbon monoxide detectors are in working order. Water temperature is within regulatory temperature range of 105-120*F. Facility temperature was 77*F.

No citations issued as a result of today's case management. An exit interview was conducted with Virginia Yadao and a copy of this report was provided to Virginia.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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