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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005056
Report Date: 06/05/2024
Date Signed: 06/05/2024 12:12:32 PM

Document Has Been Signed on 06/05/2024 12:12 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:KIZER GUEST HOME #1FACILITY NUMBER:
397005056
ADMINISTRATOR/
DIRECTOR:
KIZER, MAGDALENEFACILITY TYPE:
735
ADDRESS:8357 KILTIE WAYTELEPHONE:
(209) 401-5014
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
06/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Magdalene KizerTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On 6-5-24 at 10:11am Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Magdalene Kizer and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a adult residential care facility with a current census of 6. Facility has 4 bedrooms and 2 bathrooms. Three bedrooms are for resident use; one bedroom is for staff use.. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 ambulatory residents, 0 non ambulatory residents, 0 hospice, and 0 bedridden.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 78*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4-26-24. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 5 resident files and 3 staffing files were reviewed for regulatory compliance.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KIZER GUEST HOME #1
FACILITY NUMBER: 397005056
VISIT DATE: 06/05/2024
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All file contain necessary regulatory requirement components. All staff noted on LIC 500 contained criminal background clearances. LPA completed 2 resident interviews and 1 staff interview. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility does not contain any bodies of water. LPA observed personal rights posted. Facility does have current updated disaster plan. Facility conducts monthly fire drills. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, no citations were observed during this visit. Exit interview was held and a report was given to Administrator Magdalene Kizer.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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