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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005719
Report Date: 09/08/2022
Date Signed: 09/21/2022 02:23:46 PM

Document Has Been Signed on 09/21/2022 02:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DIGNA'S CARE HOME #1FACILITY NUMBER:
397005719
ADMINISTRATOR:CABRERA, DIGNAFACILITY TYPE:
735
ADDRESS:2955 CHRISTINA AVETELEPHONE:
(209) 598-7588
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Digna Cabrera - AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace arrived at this facility unannounced to conduct an Required 1 Year Annual Inspection Visit. LPA met with the administrator and explained the purpose of the visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. Facility is a multilevel home with grab bars on either side of stairs leading to a lower part of the facility. No obstructions to fire exits noted. There is a shed in the backyard that was unlocked upon inspection with a paint can noted to be accessible to clients in care. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 113.3*F in the kitchen and room temperature reads 75*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 5/7/22. Facility has an emergency food and water kit. LPA reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.
LPA reviewed two (2) resident facility files and all documents were in files required by Community Care Licensing (CCL).

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report with appeal rights was given to Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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