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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500314689
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:16:41 PM

Document Has Been Signed on 03/30/2022 12:16 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:SIERRA SALEM CHRISTIAN HOMES, INC.FACILITY NUMBER:
500314689
ADMINISTRATOR:DOROTHY LOPEZFACILITY TYPE:
735
ADDRESS:1545 MARSHA AVENUETELEPHONE:
(209) 544-9515
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 6DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Dorothy Lopez TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address unannounced to conduct an annual required inspection. LPA met with Administrator Dorothy Lopez and explained the reason for the visit.

LPA Lund and Administrator Dorothy Lopez walked the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies.

Fire extinguishers (1/17/2023) and smoke detectors are operational and incompliance. LPA observed centrally stored medications are kept locked and inaccessible to residents. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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