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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005590
Report Date: 03/22/2022
Date Signed: 03/23/2022 07:08:38 AM


Document Has Been Signed on 03/23/2022 07:08 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:ESCALON SENIOR ESTATEFACILITY NUMBER:
397005590
ADMINISTRATOR:RICK REEDFACILITY TYPE:
740
ADDRESS:16460 S. ESCALON BELLOTATELEPHONE:
(209) 838-0888
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:15CENSUS: DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rick ReedTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Maja Jensen and Licensing Program Manager (LPM) Liza King arrived at the facility unannounced to conduct a required 1 year annual visit. LPA Jensen and LPM King met with Licensee Rick Reed and explained the purpose of today's visit. The Licensee holds a current certificate number 6003307740.

There is a central entry point and LPA and LPM were temperature screened upon entry. LPA and LPM observed a sign in log and all required signage posted throughout the facility. There is hand sanitizer located throughout the hallways.

The facility is a single story building licensed to serve a capacity of 15 non-ambulatory residents. LPA and LPM toured the physical plant including but not limited to resident bedrooms, bathrooms, kitchen, activity room, dining room and grounds. LPA and LPM observed the facility to be odor free and clean. LPA and LPM observed sufficient furniture throughout.

LPA and LPM observed sharp objects to be kept in a locked cabinet. LPA and LPM observed sufficient seven day non-perishable food and two day perishable food supplies. The temperature in the facility was 75 degrees which falls within the required range. The water temperature in the bathroom measured at 105 degrees which also falls within the required range of 105-120 degrees. The first aid kit was observed to be complete.

No deficiencies were cited during the course of this visit. A copy of this report was printed and given to the licensee upon completion of the visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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