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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701273
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:29:53 PM

Document Has Been Signed on 08/14/2024 03:29 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:
08/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Danielle CarpenterTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 8-14-24 at 1:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a health and safety case management visit. LPA met with lead staff Danielle Carpenter (S1) and explained the purpose of the visit. Administrator Jamesha Boyd (S2) was made aware of LPAs visit and purpose and arrived at 2:20pm. Administrator departed at approximately 3:00pm due to a prior commitment.

LPA conducted brief interviews with S1, S2 and resident1 (R1). R1 moved into facility on 8-5-24 and is currently adjusting well overall to her new environment. It was determined today through interviews that R1 experienced a fall on 8-11-24 which resulted in damage to her cell phone. At this time, facility is assisting R1 with obtaining a new phone. R1 is currently on a 3-week respite and is in process of beginning a new day program attendance with assistance from facility staff.

LPA also toured facility grounds including common areas, kitchen area, client bedrooms, bathrooms, and outside of facility to ensure compliance with Title 22 regulations. Facility has 3 bedrooms and 2 bathrooms for client use. Two staff members were on duty and facility's current census is 3. Facility is maintaining adequate food supply at this time. Facility was observed to be clean and sanitary and contain all required furniture and furnishings throughout. Facility is maintaining a comfortable temperature of 70*F.

No citations issued as a result of today's case management. An exit interview was conducted with S1 and a copy of this report was provided to S1.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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