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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500314875
Report Date: 05/16/2023
Date Signed: 05/18/2023 08:43:32 AM

Document Has Been Signed on 05/18/2023 08:43 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: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:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Saudia Whitaker TIME COMPLETED:
12:00 PM
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On 05/16/2023 at 9:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greet by staff member, Lilly King, and was asked to call the Facility Designated Administrator to let them know that CCL was present at this time. Shortly after, LPA met with Facility Designated Administrator, Saudia Whitaker. This facility is licensed to served and accept up to 6 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 3 residents at this time. There were 3 other staff members present at the time of this visit, Bianca King, Domnique Brown, and India King.
Current census was 5. 3 out 5 residents were out at their respective day programs at this time.
A brief interview with the FDA Whitaker was conducted.
LPA reviewed 3 resident files. 3 out of 3 resident files have been current and up to date. LPA reviewed 3 staff files. 3 out of 3 staff files are current and up to date. The FDA has an active and current administrator's certificate #6020044735 and expires on 08/30/2024. LPA reviewed 3 out 3 resident P&I funds.
A tour of the facility was conducted.
Carbon monoxide and smoke alarms were tested and were in working condition.
The kitchen area was toured. LPA observed a sufficient amount of 2-day perishable and 7 day non-perishable food supplies in the refrigerator and cabinets. Fire extinguisher was present and was serviced on 04/18/2023. Knives were observed to be locked in a kitchen cabinet and made inaccessible to the residents at this time.
LPA observed a locked centralized stored medication located in the kitchen cabinet. Along with the administrator, the LPA 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. A staff bedroom was also toured.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DEL RIO EXTENDED FAMILY CARE
FACILITY NUMBER: 500314875
VISIT DATE: 05/16/2023
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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.

A tour of the garage was conducted. Additional perishable food supply was identified. Emergency kits were observed to be present. Laundry detergent, bleach, and all other cleaning supplies were present and were observed to be locked and made inaccessible to the residents.

A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits were inspected with no hazards present.



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

-LIC 308

-LIC 400

-LIC 500

-LIC 610

No deficiencies were observed or cited during this annual visit.


Exit interview interview was conducted. A copy of this report was given to the facility via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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