<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:09:43 PM

Document Has Been Signed on 08/08/2024 12:09 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:HAYNES BOARD AND CAREFACILITY NUMBER:
392790075
ADMINISTRATOR/
DIRECTOR:
PARKER, CHERYLFACILITY TYPE:
735
ADDRESS:17201 N. TULLY ROADTELEPHONE:
(209) 727-5834
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 30CENSUS: 19DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Sandra Haynes-Andrews and Melissa GirardotTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/08/2024 at 11:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Sandra Haynes-Andrews and Melissa Girardot and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for 30 ambulatory clients. There are currently 19 clients who reside at this facility.

The LPA Martinez toured the facility with Sandra Haynes-Andrews on 08/08/2024 at 11:15 AM.

LPA Martinez reviewed 5 client files and 3 staff files, which were complete. The facility has an infection control plan and a natural disaster plan. LPA Martinez reviewed 1 PNI file and 1 medication administration record which were maintained. Fire extinguishers and carbon detectors were in good repair. The facility has locked gated swimming pool, and a covered patio for client use. The facility has an adequate food supply. Facility bedrooms, bathrooms, common areas, kitchen, and laundry room were sanitary and furnished. The facility water temperature measured 105 degrees and facility temperature measured at 75 degrees.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was conducted, and a copy of this report was given to the facility at the end of the visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1