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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500314875
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:42:27 PM

Document Has Been Signed on 06/16/2022 04:42 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:DEL RIO EXTENDED FAMILY CAREFACILITY NUMBER:
500314875
ADMINISTRATOR:KING, SAUDIAFACILITY TYPE:
735
ADDRESS:3813 WESSON RANCH ROADTELEPHONE:
(209) 523-6877
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Saudia WhittakerTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua conducted an unannounced required-1 Year annual inspection visit on 06/16/2022. LPAs met with the facility designated Administrator, Saudia Whittaker. It was observed that the administration certificate for Saudia Whittaker was due to expire on 08/12/2022. There was one other staff member present, Sheila Griffiths.

The current census was 5 residents.

A tour of this facility was conducted.

The kitchen area was toured. LPAs observed perishable and non perishable food supplies in the refrigerator and cabinets. Fire extinguisher was present and was set to expire on 02/23/2023. Knives were observed to be locked in a kitchen cabinet and made inaccessible to the residents at this time.

LPAs observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPAs observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the 3 bedrooms was conducted. Furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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: DEL RIO EXTENDED FAMILY CARE
FACILITY NUMBER: 500314875
VISIT DATE: 06/16/2022
NARRATIVE
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A tour of the garage was conducted. Additional storage for cleaning supplies were stored in cabinets.

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were present.

A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits were inspected.



The following forms and documents were requested to be updated and submitted into CCL

-LIC 200

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Updated Plan of Operations

-Facility Sketch

-Admissions Agreement

-Program Description

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.



Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/16/2022 04:42 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/16/2022 at 11:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DEL RIO EXTENDED FAMILY CARE
FACILITY NUMBER: 500314875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not providing a sufficient amount of perishable and non-perishable food supplies which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Licensee agrees to go pick up groceries to maintain a sufficient amount of perishable and non-perishable food supplies. Licensee will send a reciept to LPA by 06/17/2022.
Type A
Section Cited
HSC
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not locking disinfectants, cleaning solutions, poisons, and other items which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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While discussing deficiency with the licensee locked disinfectants and made them inaccessible to the residents at this time while LPA was present.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/16/2022 04:42 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/16/2022 at 11:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DEL RIO EXTENDED FAMILY CARE
FACILITY NUMBER: 500314875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
8088(b)

(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited since the window screens were not present and residents may not open their windows without pests entering the facility, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Licensee agrees to purchase a window screennd send the receipt and picture in to the LPA's email by 6/23/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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