502700233-8-16-2024-27-AS-JLUD-D87KXU-20240816081804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700233
Report Date: 08/15/2024
Date Signed: 08/16/2024 08:18:10 AM

Document Has Been Signed on 08/16/2024 08:18 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DAVIS GUEST HOME #8		FACILITY NUMBER:	502700233
ADMINISTRATOR:	SPEEGLE, MISTY		FACILITY TYPE:	740
ADDRESS:	5348 KIERNAN AVENUE		TELEPHONE:	(209) 622-2042
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 72	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Misty Speegle		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA was met by Administrator Misty Speegle and explained the purpose of the visit. Census:72 This facility is licensed to serve and retain 80 residents who are 60 and over. Of which 12 may be non-ambulatory in rooms 15-20 only. Census 72 LPA Lund reviewed 7 residents files. 7 out of 7 resident files were current and up to date. LPA reviewed 7 staff files. 7 staff files were current and up to date. A tour/Inspection of the facility was conducted with Administrator Misty Speegle & LPA Jason Lund. The facility has 3 separate wings that house residents who are in shared bedrooms 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. Medication carts were observed to be present. 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.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS GUEST HOME #8	FACILITY NUMBER: 502700233
	VISIT DATE: 08/15/2024

NARRATIVE

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Policies and procedures were discussed in relation to narcotics and medications that required a separate count and documentation by incoming staff and outgoing staff. 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 08/1/2024 by the local fire extinguisher company, Jorgenson Co, and observed to be in compliance at this time. Laundry rooms were toured. Chemicals, detergents, and bleaches were observed to be locked and made inaccessible to the residents at this time. Kitchen area was toured. 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.

Based on the observations made during this visit, there were no deficiencies observed or cited during today's annual visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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