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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701273
Report Date: 08/07/2024
Date Signed: 08/07/2024 01:12:10 PM

Document Has Been Signed on 08/07/2024 01:12 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: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:
08/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Amiyah KnoxTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check on this day. LPA met with A. Knox. Later joined by Administrator.

R1 has been at the facility for approximately two days and is doing well with other residents and staff. R1 has a phone but the charger for the phone was miss placed by R1 and the facility will assist her in getting a new phone charger. R1 is on a three week respite.

LPA Johnson also toured the facility including R1's room. R1 is not attending a day program at this time. The facility is working with the Regional Center to find a program.

Health and Safety check included food supply, physical plant and staffing.

No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.


Exit interview conducted
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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