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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700233
Report Date: 09/09/2021
Date Signed: 03/29/2022 08:21:25 AM

Document Has Been Signed on 03/29/2022 08:21 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 #8FACILITY NUMBER:
502700233
ADMINISTRATOR:SPEEGLE, MISTYFACILITY TYPE:
740
ADDRESS:5348 KIERNAN AVENUETELEPHONE:
(209) 622-2042
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 80CENSUS: 75DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Misty Speegle, Administrator TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to conduct a case management visit on a death report received on September 7, 2021. LPA met with Administrator Misty Speegle and discussed the purpose for today's visit. LPA reviewed the client's 602, and medication reports. LPA requested the death certificate be sent to her once it is received by the facility.

An exit interview was conducted with Administrator Misty Speegle and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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