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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701273
Report Date: 05/20/2024
Date Signed: 05/21/2024 06:35:25 AM

Document Has Been Signed on 05/21/2024 06:35 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DA VINCI HOUSEFACILITY NUMBER:
392701273
ADMINISTRATOR/
DIRECTOR:		BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:4511 DA VINCI DRTELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 3DATE:
05/20/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 PM
MET WITH:J. BoydTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 5/20/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced for a post licensing visit. There are three residents in care. The facility has completed it's vendorization with VMRC.

LPA toured the exterior of the facility including the common areas, bathrooms, residents room and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed the following posted in the facility: See Something Say Something complaint poster, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been serviced. The facility has one resident that is on a respite, the other two are permanent residents.

No deficiencies are cited during today's inspection.

Exit interview and copy of report provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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