500309303-9-19-2023-27-AS-CYAG-CVTP8N-20230919110550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500309303
Report Date: 09/18/2023
Date Signed: 09/19/2023 11:05:56 AM

Document Has Been Signed on 09/19/2023 11:05 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	J & L GUEST HOME		FACILITY NUMBER:	500309303
ADMINISTRATOR:	ANITA NIEL		FACILITY TYPE:	740
ADDRESS:	237 S ABBIE STREET		TELEPHONE:	(209) 527-2765
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	32	CENSUS: 29	DATE:	09/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Renee Little		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 09/18/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Renee Little who was briefly interviewed at this time. Also present was the facility House Manager Sarah Rico who was briefly interviewed as well. Current census was 29 residents. It was learned that not all of the residents were present at this time since several of them were out of the home at their respectable day programs at this time. This facility is vendorized to accept and retain Level 3 residents through Valley Mountain Regional Center. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Renee Little. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date. 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 an additional food storage unit which was present and functional at this time in the designated staff room. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the facility 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. First aid kit was observed to be present and contained all of the required components at this time. A tour of the resident bedrooms and restrooms 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. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: J & L GUEST HOME	FACILITY NUMBER: 500309303
	VISIT DATE: 09/18/2023

NARRATIVE

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linens to meet the needs of the residents 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 05/18/2023 by the local fire extinguisher company, USA Stanislaus Fire, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
It was observed that there was an additional classroom/theater room, present on facility grounds at this time. Decorations and additional maintenance supplies were observed to be present while this space was locked and made inaccessible to the residents at this time.
A review of (5) facility resident records was conducted.
A review of (5) facility staff records 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 today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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