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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332307
Report Date: 09/20/2023
Date Signed: 09/26/2023 11:31:27 AM

Document Has Been Signed on 09/26/2023 11:31 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DAVIS GUEST HOME #2FACILITY NUMBER:
500332307
ADMINISTRATOR:VALERIA OROZCOFACILITY TYPE:
735
ADDRESS:1900 EAST HATCH ROADTELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 49CENSUS: 49DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Valeria OrozcoTIME COMPLETED:
02:30 PM
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Unannounced annual visit made out to this facility on 09/20/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Valeria Orozco. Brief interview was conducted with the facility designated Administrator at this time.
Current census was 49 residents.
It was learned that the residents were either out of the facility in the community at this time or present in their rooms and common areas. This facility was not vendorized to accept or retain any residents through Valley Mountain Regional Center at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Valeria Orozco. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities as observed in the rear garage, and storage area, at this time. This LPA did observe that all of the food supplies were maintained for most of the Davis Guest Homes within the area.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinets, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinets were observed to be locked and made inaccessible to the residents at this time.
First aid kits were observed to be present and contained all of the required components at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures was taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and
linens to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DAVIS GUEST HOME #2
FACILITY NUMBER: 500332307
VISIT DATE: 09/20/2023
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Garage area was toured. This area has been converted as a storage room to house additional furniture and supply needs for the facility residents. In addition, food supplies were also located in this area as well.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/08/2023 by the local fire extinguisher company, Jorgensen Co, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
It was observed that there were several sheds present on facility grounds at this time. Decorations and additional maintenance supplies were observed to be present while these sheds were locked and made inaccessible to the residents at this time.
A review of (5) facility resident records was conducted.
A review of (5) facility staff records 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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