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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202987
Report Date: 03/23/2023
Date Signed: 03/24/2023 08:53:11 AM

Document Has Been Signed on 03/24/2023 08:53 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 5TH STREETTELEPHONE:
(209) 471-5627
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 6DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Remy RaquenoTIME COMPLETED:
12:00 PM
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On 03/23/2023 at 9:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an Annual Visit. LPA Pascua met with Facility Designated Administrator, Remy Raqueno and explained the purpose of the visit. This facility is licensed to serve up to 6 residents of which 5 may be non-ambulatory. This facility is also vendorized by Valley Mountain Regional Center to serve and accept Level 3 residents at this time. The administrator holds an active and current administrator certification #6009143735 and expires on 12/26/2023.
Current census was 6. 6 out of 6 residents were out at their respective day program.
LPA reviewed 6 resident files. 6 out of 6 resident files are current and up to date. LPA reviewed 4 staff files. 4 out of 4 files are current and up to date.
A tour of the facility was conducted. A fire extinguisher was identified in the kitchen and was serviced by Butch Young Fire Equipment Inc on 03/06/2023.
The kitchen area was toured. LPA 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.
LPA observed a locked centralized stored medication cabinet. Along with the administrator, the LPA 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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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: 03/23/2023
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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..
A tour of the 3 resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.
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
-Liability Insurance

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview was conducted. .
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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