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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005277
Report Date: 03/10/2022
Date Signed: 03/11/2022 08:16:22 AM

Document Has Been Signed on 03/11/2022 08:16 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: 95CENSUS: 14DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Deanna Smith, Program ManagerTIME COMPLETED:
01:10 PM
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Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conducted a 1-Year Required annual inspection. LPAs met with Program Manager (PM) Deanna Smith and explained the purpose of the visit.

LPAs toured the facility including but not limited too, activity rooms, a common area, kitchen area and facility bathrooms. LPAs observed rooms clean, organized and in good repair. Hot water temperature measured at 120 degrees F. in the women's bathroom and 119.7 degrees F. in the men's bathroom. LPAs reviewed 4 client and 4 staff records.

Fire drill last conducted on 02/28/2022. 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. LPAs observed smoke alarms and carbon monoxide detectors interconnected with the fire department. Fire extinguishers were mounted and charge expiration date of 06/08/2022. First aid kit observed to be complete.

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 report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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