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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700233
Report Date: 04/07/2021
Date Signed: 05/12/2021 08:34:35 AM

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 #8FACILITY NUMBER:
502700233
ADMINISTRATOR:SPEEGLE, MISTYFACILITY TYPE:
740
ADDRESS:5348 KIERNAN AVENUETELEPHONE:
(209) 622-2042
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 52DATE:
04/07/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Misty SpeegleTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check on this day. LPA met with Administrator.

Health and Safety check included overall safety of the facility including Staffing, health of residents and building and grounds

The LPA toured the physical plant to ensure the health and safety of residents in care. LPA requested copies of documented from R1's file. During today's inspection, LPA was made aware that R1 AWOL'd through the back area and jumped a fence which was caught on video. The facility does not have any additional information regarding R1's time of death.


Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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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