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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500307165
Report Date: 09/13/2021
Date Signed: 09/14/2021 01:57:52 PM

Document Has Been Signed on 09/14/2021 01:57 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:LITTLE'S GUEST HOMEFACILITY NUMBER:
500307165
ADMINISTRATOR:LAURA WOODINGFACILITY TYPE:
735
ADDRESS:213 S ABBIE STREETTELEPHONE:
(209) 524-2163
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY: 22CENSUS: 21DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sabrina Mendez and Laura ProctorTIME COMPLETED:
03:30 PM
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Unannounced annual visit made out to this facility on 09/13/2021 by this LPA who was met by the facility house manager, Sabrina Mendez, and the facility designated Administrator, Laura Proctor, who were briefly interviewed at this time.
Current census was 21 residents.
This facility is licensed to serve and accept up to 22 residents who are deemed to be ambulatory and non ambulatory as well. This facility is able to accept and retain vendorized Level II residents.
Tour of the facility was conducted.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and drawers were reviewed for adequate supplies at this time.
Food storage units, facility refrigerator unit and freezer unit, were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Pantry area housing dry goods and products was toured as part of the facility laundry room. Medication cabinet, located in kitchen area, was reviewed at this time. Policies and procedures were discussed with the facility staff in regards to dispensing, documenting, and communication for all involved parties. Medication with narcotic lock boxes and separate refrigeration units for such medications were observed to be in use at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to have been annually inspected on 09/22/2020 by the local fire equipment company and found to be in compliance at this time. Discussion was held with facility personnel that the due date was fast approaching and informed that a schedule was already in place for the annual review.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and in compliance at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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: LITTLE'S GUEST HOME
FACILITY NUMBER: 500307165
VISIT DATE: 09/13/2021
NARRATIVE
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Activity area was toured as well.
Linen supplies were reviewed and observed to be in compliance at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits was conducted.

This LPA requested the following forms and documents from this facility to be updated and submit into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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