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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700233
Report Date: 05/20/2024
Date Signed: 05/20/2024 12:04:47 PM


Document Has Been Signed on 05/20/2024 12:04 PM - 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 #8FACILITY NUMBER:
502700233
ADMINISTRATOR:SPEEGLE, MISTYFACILITY TYPE:
740
ADDRESS:5348 KIERNAN AVENUETELEPHONE:
(209) 622-2042
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 78DATE:
05/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Zachary DavisTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived to the facility unannounced to conduct a case management visit and met with Administrator Zachary Davis and explained the reason for the visit. Census: 78

On May 15, 2024, CCL received an Unusual Incident/Injury Report and Death report that Client (C1) had passed away of natural causes. LPA Lund discussed situation with the facility and requested paperwork from the facility.

An exit interview and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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