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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500314689
Report Date: 04/08/2024
Date Signed: 04/12/2024 10:02:51 AM

Document Has Been Signed on 04/12/2024 10:02 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIERRA SALEM CHRISTIAN HOMES, INC.FACILITY NUMBER:
500314689
ADMINISTRATOR/
DIRECTOR:
DOROTHY LOPEZFACILITY TYPE:
735
ADDRESS:1545 MARSHA AVENUETELEPHONE:
(209) 544-9515
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 5DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator Dorothy Lopez TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with Administrator Dorothy Lopez and explained the reason for the visit. Census:6

LPA Lund and Administrator Dorothy Lopez walked the physical plant including but not limited to the kitchen, dining room, six residents bedrooms; three 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 (12/11/2023) and smoke detectors are operational and incompliance. The facility also has a sprinkler system. 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. Hot water temperature was measured at 113 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. LPA Lund reviewed two staff & two clients files are in compliance.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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