502700233-9-1-2023-27-AS-APAA-CV9L4J-20230901082533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700233
Report Date: 08/31/2023
Date Signed: 09/01/2023 08:25:57 AM

Document Has Been Signed on 09/01/2023 08:25 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 #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: 79	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Zachary Davis		TIME COMPLETED:	02:00 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	On 08/31/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA was met with Licensee, Zachary Davis and explained the purpose of the visit. 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. Current census was 79. A brief interview with Licensee Davis was conducted. LPA reviewed 15 residents files. 15 out of 15 resident files were current and up to date. LPA reviewed 7 staff files. 7 staff files were current and up to date. Administrator has a current RCFE certificate #6062737740 and expires on 08/30/2024. At 11:50am, a tour of the facility was conducted. It was learned during this visit that 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. 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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS GUEST HOME #8	FACILITY NUMBER: 502700233
	VISIT DATE: 08/31/2023

NARRATIVE

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Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/08/2023 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.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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 to the Licensee at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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