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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332206
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:26:02 AM

Document Has Been Signed on 11/04/2022 11:26 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 GUEST HOMEFACILITY NUMBER:
500332206
ADMINISTRATOR:SILER, DOROTHYFACILITY TYPE:
735
ADDRESS:2841 PATTERSON RDTELEPHONE:
(209) 869-2420
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 15CENSUS: 11DATE:
11/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Saudia WhitakerTIME COMPLETED:
11:30 AM
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At 11:00 am on 11/4/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit for an incident involving resident 1 (R1) that left the facility and did not return. LPA Jensen met with Licensee Saudia Whitaker.

The resident has been located. See LIC 812 for additional details. LPA Jensen requested a copy of the resident sign out sheet and Individual Program Plan to be emailed to maja.jensen@dss.ca.gov by 11/10/22.

No deficiencies were cited as a result of this visit.

An exit interview was conducted and a copy of this report was given to the Licensee
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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