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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701250
Report Date: 04/07/2023
Date Signed: 04/07/2023 10:35:30 AM


Document Has Been Signed on 04/07/2023 10:35 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:YANNICA GUEST HOME 2FACILITY NUMBER:
392701250
ADMINISTRATOR:MARTIN, MAXIMAFACILITY TYPE:
740
ADDRESS:3956 NOVARA WAYTELEPHONE:
(510) 366-6585
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 6DATE:
04/07/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maxima Martin, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Renee Campbell arrived unannounced and conducted a Post Licensing inspection of the facility on this day, April 7, 2023 starting at 9:15 AM. LPA was greeted by Maxima Martin, Administrator. LPA inspected the facility inside and out. Facility had 6 residents during the inspection. When LPAs came,5 residents were sitting in the living room watching tv. One other was at the dialysis center.. Food supply was checked and LPAs observed at least 1-week and 2-day supply of nonperishable and perishable foods, respectively. Centrally stored medications were locked in a closet. Fire extinguishers were last inspected on 2/09/2023. First aid kit was complete with manual. Carbon monoxide and smoke detectors were observed operational during visit. . The facility’s fire clearance was approved for five non-ambulatory residents and one bedridden. PRN medications have written order from a physician. Toxic chemicals are stored in the laundry room and locked..

Facility temperature is maintained at 73 degrees Fahrenheit. Hot water temperature measures 115 degrees Fahrenheit in one of the bathrooms. Each room is provided with working lights. There are grab bars for each residents' shower and toilet. Hallways and passages are free of obstruction. Hygiene supplies and toiletries are available.

Certified administrator is on site approximately 20 hours per week to oversee the business operation. The facility has trained staff to meet the residents’ needs. Staff who assist with activities of daily living and medication have the necessary basic and medication training.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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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