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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202987
Report Date: 05/12/2022
Date Signed: 05/17/2022 10:03:32 AM

Document Has Been Signed on 05/17/2022 10:03 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:LATHROP RANCH HOMEFACILITY NUMBER:
397202987
ADMINISTRATOR:RAQUENO, REMYFACILITY TYPE:
735
ADDRESS:15198 SOUTH FIFTH STREETTELEPHONE:
(209) 471-5627
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 6DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Remy Requeno TIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua conducted an unannounced Annual/Infection Control visit on 05/12/2022. LPAs met with Facility Designed Administrator, Remy Raqueno. Her administrator license expires on 12/26/2023. Two staff members were present, Maria Gudoy and Benilda Natividad. Census was currently at full capacity with 6 residents.

A tour of this facility was conducted.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected and was valid until 10/29/2022.
The kitchen area was toured. LPAs observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Soap and cleaning supplies under the sink were locked. Additional non-perishable food supplies were identified in the garage.
LPAs observed a locked centralized stored medication cabinet. Along with the administrator, the LPAs observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the bathrooms was conducted. No soap or cleaning supplies were stored under the sinks. Hot water temperature was within the required range of 105-120 degrees. All Linen closets located in the hallways presented a sufficient amount of linen to supply for resident bedding.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LATHROP RANCH HOME
FACILITY NUMBER: 397202987
VISIT DATE: 05/12/2022
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The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL:

-LIC 308
-LIC 400
-LIC 500
-LIC 610
-Copy of admission agreement.

No deficiencies were observed or cited during this annual visit.

Exit interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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