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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005277
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:21:19 PM

Document Has Been Signed on 03/27/2024 12:21 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: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: 85DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Deanna Smith TIME COMPLETED:
12:25 PM
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On 03/27/2024 at 10:45 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Deanna Smith 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 95 ambulatory clients. During today's annual inspection, there were 21 staff and 62 clients.

The LPA Martinez toured the facility with Deanna Smith on 03/27/2024 at 11:30 AM.

LPA Martinez conducted a facility file review. LPA Martinez reviewed five client files, and all files were maintained. LPA Martinez reviewed five staff files, and all files were maintained . The facility also has an infection control plan, fire and safety plan, and natural disaster plan. Facility's last fire inspection was on Jan 23, 2023. 2024 fire inspection is pending due to requesting a new STD. 850. Fire extinguishers are in good repair. First aid kit is complete. Facility temperature water measured at 106 degrees, and the facility temperature measured at 70 degrees. The day program does not dispense medications. The day program only provides snacks. The day program has a patio area for client use, which is in good repair.

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, and an exit interview was conducted. A copy of this report was provided to the day program.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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