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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701273
Report Date: 08/10/2023
Date Signed: 08/10/2023 12:21:38 PM

Document Has Been Signed on 08/10/2023 12:21 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:DA VINCI HOUSEFACILITY NUMBER:
392701273
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:4511 DA VINCI DRTELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 0DATE:
08/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jamesha BoydTIME COMPLETED:
12:30 PM
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On 8/10/23 at approximately 10:15 Licensing Program Analyst (LPA) Maja Jensen arrived at facility for a scheduled pre-licensing inspection. LPA Jensen met with Licensee Jamesha Boyd and explained the pre-licensing inspection process.

LPA Jensen toured the grounds and observed that they are well maintained and all paths are free of obstruction. There are no bodies of water on the property. The facility has outdoor furniture and shade available for client use.

LPA Jensen toured the interior of the facility and observed it to be odor free and sanitary. The facility has 3 bedrooms and 2 baths. The facility has been granted fire clearance for 4 of which 1 can be non-ambulatory. The thermostat was set at a comfortable temperature. LPA Jensen observed postings for personal rights, abuse reporting, emergency disaster plans and an activity schedule. The carbon monoxide detector and smoke detector were tested and found to be in good working order. The fire extinguisher was determined to be in compliance. There is an emergency food supply and emergency lighting available. The facility maintains a first aid kit that is complete with tweezers, scissors, thermometer, various wound dressings and manual. Toxins, medications and staff/resident files will be maintained in a locked cabinet. The washer and dryer and are located in the garage and the garage will remain locked and inaccessible to residents in care.

The bathrooms have non-slip mats and there are night lights available in the hallway. The water temperature in the bathroom located in the master bedroom was measured at 106 degrees Fahrenheit which falls within the required regulatory range of 105 degrees to 120 degrees. The facility maintains an adequate supply of linens.

Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DA VINCI HOUSE
FACILITY NUMBER: 392701273
VISIT DATE: 08/10/2023
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Continued on LIC 809...
The facility has three bedrooms of which one is currently set up for double occupancy and two are set up for single occupancy. All bedrooms are equipped with a chair, night stand, dresser, and reading lamp.

The facility was determined to be in substantial compliance and has passed the pre-licensing inspection.

A Component III presentation was conducted. An exit interview was conducted and a copy of this report was provided to Jamesha Boyd.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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