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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500314875
Report Date: 06/16/2025
Date Signed: 06/16/2025 11:09:01 AM

Document Has Been Signed on 06/16/2025 11:09 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:DEL RIO EXTENDED FAMILY CAREFACILITY NUMBER:
500314875
ADMINISTRATOR/
DIRECTOR:		KING, SAUDIAFACILITY TYPE:
735
ADDRESS:3813 WESSON RANCH ROADTELEPHONE:
(209) 523-6877
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
06/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Shiela McGintyTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 06/16/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Staff member (SM), Lillie King and explained the purpose of the visit. LPA Pascua asked SM King to call the Facility Designated Administrator (FDA), Saudia King to inform her that CCL was present at this time. Shortly after, LPA met with Facility Designated Representative, (FDR) Sheila McGinty
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.
Current census was 5. 5 out 5 residents were out at their respective day program at this time.
A brief interview with the FDR McGinty was conducted.
LPA reviewed 5 resident files. 5 out of 5 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 #7034047635 and expires on 08/30/2026. The FDR also has an active and current administrator's certificate #6076209735 and expires on 03/16/2027. It was stated that FDR McGinty will be the administrator moving forward.
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 02/21/2025. 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DEL RIO EXTENDED FAMILY CARE
FACILITY NUMBER: 500314875
VISIT DATE: 06/16/2025
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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.
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 610e

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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
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