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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004626
Report Date: 05/25/2022
Date Signed: 05/25/2022 11:08:23 AM

Document Has Been Signed on 05/25/2022 11:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LJ GUEST HOMEFACILITY NUMBER:
397004626
ADMINISTRATOR:YADAO, VIRGINIAFACILITY TYPE:
735
ADDRESS:8816 DAMIAN COURTTELEPHONE:
(209) 476-0383
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Virginia YadaoTIME COMPLETED:
11:17 AM
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On 5-25-22 at 10:08am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Virginia Yadao and explained the purpose of the visit. Facility is a 5 bed Adult Residential Facility with a current census of 4. All rooms are private accommodations and located down a hallway corridor.

At 10:15am LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool. At 10:32am all door alarms were tested and functioning properly.
The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and backyard. The backyard area has two tool sheds which are inaccessible to clients in care. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Six staff records were reviewed during inspection. All records contained current COVID-19 and First Aid certifications.

At 10:45am LPA tested water temperature which is within the range of 105-120*F in the bathroom and observed room temperature which read 78*F. LPA observed the facility to have adequate food supply of 7 days non-perishable and 2-day perishable. At 11:00am, LPA observed resident rooms to be sanitary and had the required furniture and other furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair and operable. Fire extinguisher was checked December 2, 2021.

Per California Code of Regulations, Title 22, Division 6 no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Virginia Yadao
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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