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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332307
Report Date: 09/10/2021
Date Signed: 09/14/2021 02:00:10 PM

Document Has Been Signed on 09/14/2021 02:00 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:DAVIS GUEST HOME #2FACILITY NUMBER:
500332307
ADMINISTRATOR:MELISSA GREENFACILITY TYPE:
735
ADDRESS:1900 EAST HATCH ROADTELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 49CENSUS: 48DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Heather McCloskyTIME COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 09/10/2021 by this LPA who was met by the facility designated Administrator, ,Heather McClosky who was briefly interviewed at this time.
Current census was 48 residents.
This facility is licensed to serve and accept up to 49 residents who are deemed to be ambulatory and non ambulatory as well. This facility is composed of (2) building wings designated for male and female residents. Tour of the facility was conducted.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. It was learned that kitchen staff are not separate in terms of duties and can double as care providers as well.
Food storage units, facility refrigerator unit and freezer unit, were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Pantry area housing dry goods and products was toured. Medication rooms, located in the staff lounge, was toured. Policies and procedures were discussed with the medication technicians at this time in regards to dispensing, documenting, and communication for all involved parties. Medication carts were being used with narcotic lock boxes and separate refrigeration units for such medications.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to have been annually inspected on 09/20/2020 by the local fire equipment company and found to be in compliance at this time. Discussion was held with facility representative about upcoming due date and fire equipment company was present while this LPA conducted this visit.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and in compliance at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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: DAVIS GUEST HOME #2
FACILITY NUMBER: 500332307
VISIT DATE: 09/10/2021
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Activity center was toured as well.
Linen supplies were reviewed and observed to be in compliance at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits was conducted.

This LPA requested the following forms and documents from this facility to be updated and submit into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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