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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005277
Report Date: 11/18/2021
Date Signed: 11/19/2021 08:05:46 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/19/2021 08:05 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:PERSON CENTERED SERVICES, INC. #3FACILITY NUMBER:
397005277
ADMINISTRATOR:CHERYL ELLIOTTFACILITY TYPE:
775
ADDRESS:651 NORTH CHEROKEE LN., STE. ETELEPHONE:
(209) 466-2448
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 95; 95; 95CENSUS: 14DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Program Director - Deanna SmithTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced visit on this day for the purpose of conducting a Required - 1 Year Evaluation. LPA arrived at 10:15 AM and met with Program Manager (PM) Deanna Smith.
This program has a 1:3 ratio. Based on staffing, the facility is within ratio requirements. LPA and PM toured the facility inside and out. LPA inspected 3 activity rooms, a common area, kitchen area and facility bathrooms. LPA observed rooms clean, organized and in good repair. LPA reviewed 5 client and 5 staff records. LPA reviewed files for the following but not limited to physician's report, IPP and personal rights with no concerns noted. A review of staff records indicates that all facility staff have received criminal record clearances and were associated to the facility. Staff records reviewed indicated current first aid certificates as well as annual staff training as required. The last fire drill was conducted on 11/15/2021. The facility does not administer medications nor does the facility keep P&I monies for clients. Exits were observed to be accessible to clients and free from obstructions. All facility vehicle registrations were current. Smoke alarms and carbon monoxide detectors were observed operational. Fire extinguishers were mounted and charge expiration date of 06/08/2022.
The following documents needed to be submitted to LPA Wallace CCL by January 11, 2022:
Admissions Policies and Procedures, Articles of Corporation, Lease for Property, Plan of Operation, Fire Clearance, Administrator Certificate, and Transportation Policies, and a copy of Liability Insurance
LIC 308 Designation of Administrative Responsibility, LIC 309 Administration Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed or cited today.
An exit interview was conducted with PM and a copy of this report was provided along with confidential list staff and client files reviewed
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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