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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332307
Report Date: 09/12/2022
Date Signed: 09/13/2022 10:34:53 AM

Document Has Been Signed on 09/13/2022 10:34 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: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:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Misty SpeegleTIME COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 09/12/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Misty Speegle who was briefly interviewed.
This facility is licensed to accept and retain up to 49 residents at any given time.
Current census was 48 residents.
Tour of this facility was conducted alongside the facility designated Administrator Misty Speegle.
It was learned that there were two wings to this facility on the west and east. Each wing was used to house strictly males (east wing) and strictly females (west wing) at this time.
A tour of the facility resident rooms was conducted. Resident furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured and observed to be able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at this time.
Kitchen area was toured.
Medication carts were observed to be present in the kitchen area. Policies and procedures were discussed with facility staff in terms of dispensing, documenting, and overall administration of resident medications.
First aid kits were observed to be present and contained all of the necessary components at this time.
Policies and procedures were discussed in relation to narcotics and medications that required a separate count and documentation by incoming staff and outgoing staff. A review was conducted in regards to this documentation of the resident narcotics.
Living area, dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/15/2022 by the local fire extinguisher company, Gateway Fire Extinguisher, and observed to be in compliance at this time.
Laundry rooms were toured. Chemicals, detergents, and bleaches were observed to be locked and made
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 09/12/2022
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inaccessible to the residents at this time.
It was learned that the food supply was mainly stored in the back unit of Davis Guest Home #1. This area served as the main hub for food storage and distribution to the other care homes under this Licensee. A review of the food supply was conducted to make sure that there was a sufficient amount of 2-day perishable and 7-day nonperishable quantities at all times.
A commercial washer was also present in this area to wash and clean bedding for all facility residents. Additional cleaning supplies, detergents, and bleach were observed to be stored in this area as well.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted 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: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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