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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701410
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:01:02 PM

Document Has Been Signed on 05/02/2024 12:01 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:PRISCILLA LANE CARE HOME LLCFACILITY NUMBER:
392701410
ADMINISTRATOR/
DIRECTOR:
LEGASPI, JANICEFACILITY TYPE:
735
ADDRESS:9638 PRISCILLA LANETELEPHONE:
(209) 662-2260
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 4CENSUS: 0DATE:
05/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Janice Legaspi TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/02/2024 at 10:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Martinez met with Janice Legaspi and explained the purpose of todays visit.

Facility has a fire clearance for four ambulatory clients. Janice Legaspi will be the Administrator of this facility and holds a current administrator certificate.

LPA Martinez inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. During today's pre-licensing visit, the facility was in compliance with Title 22 Regulations. The facility common areas, bedrooms, bathrooms, kitchen, and laundry room were furnished and sanitary. The exterior of the facility is clear of debris, and has a shaded sitting area for client use. The exterior emergency gate is in good repair.

Additionally, the facility has a first aid kit, and locked cabinet for medication storage. The fire extinguisher, smoke detectors, and carbon detectors were in good repair. The facility has a natural disaster plan, infection control plan, and fire drill log. The facility has no large bodies of water. The facility has employee and client files.

The applicant has passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. In addition, component 3 was completed during the pre-licensing inspection visit.

An exit Interview was held, and a copy this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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