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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500309303
Report Date: 09/21/2022
Date Signed: 09/27/2022 11:13:24 AM


Document Has Been Signed on 09/27/2022 11:13 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:J & L GUEST HOMEFACILITY NUMBER:
500309303
ADMINISTRATOR:ANITA NIELFACILITY TYPE:
740
ADDRESS:237 S ABBIE STREETTELEPHONE:
(209) 527-2765
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:32CENSUS: 28DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anita NielTIME COMPLETED:
02:00 PM
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Unannounced annual visit made out to this facility on 09/21/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Anita Niel, who was briefly interviewed. It was learned that there were (7) residents, out of the total number of facility residents, who were at their respectable day programs at this time.
Staff ratios were maintained to make sure that residents were receiving adequate care and supervision at this time.
Current census was 28 residents.
A tour of this facility was conducted alongside the facility designated Administrator Anita Niel.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Anita Niel.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time in the exterior patio area.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in the office area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees. Grab bars and non skid mats were observed to be present and in good repair at this time.
Linen closets, located in the rear of this facility, was observed to contain a sufficient supply of towels, blankets, and linens sufficient to meet the needs of the residents at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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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: J & L GUEST HOME
FACILITY NUMBER: 500309303
VISIT DATE: 09/21/2022
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Exterior patio area was toured. This area was used to house additional furniture and supplies for the facility residents.
First aid kit was observed to be present and contained all of the necessary components at this time.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 05/19/2022 by the local fire extinguisher company, USA, and in compliance at this time.
Additional building in the rear of this property address was toured. It was observed that it had been converted to a movie theater setting. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during todays annual visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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