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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700447
Report Date: 01/12/2022
Date Signed: 01/12/2022 03:09:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/12/2022 03:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ENSLEN HOUSEFACILITY NUMBER:
502700447
ADMINISTRATOR:RODRIGUEZ YIEN, ELIZABETHFACILITY TYPE:
735
ADDRESS:1113 ENSLEN AVETELEPHONE:
(925) 594-0124
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 0DATE:
01/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Care staff Clara RodriguezTIME COMPLETED:
03:30 PM
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LPA Jason Lund arrived at the above facility and was met by care staff Clara Rodriquez to conduct an annual required visit. LPA spoke with Administrator Elizabeth Rodriguez and explained the reason for the visit.
The care home yet to accept any residents.

LPA conducted a tour inside and outside the facility. LPA observed the back yard with secure fence and adequate outdoor seating, and no pool or bodies of water were observed. There is a storage shed in the back yard that is locked and secured.

LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed bedrooms and living areas to be adequately furnished and LPA observed adequate supply of linens on hand. LPA tested water temperature in resident bathroom and kitchen sink at 115.degrees F . LPA observed bathroom to be in sanitary condition and maintained. Cleaning supplies and chemicals are stored in a locked cabinet.

LPA observed a first aid kit and fire extinguishers maintained and ready for emergency use and a fire clearance is for 6 ambulatory clients. Smoke detectors are hard wired and care home has a functioning carbon monoxide detector.

Emergency exit and phone number are posted, facility telephone is installed (209) 857-5725 and is working. LPA observed all other required postings hanging on a wall near the entrance of the care home, and there is a closet designated for activities and activity supplies. Medications and confidential paperwork will be stored in separate locked cabinets.

No deficiencies were observed during the inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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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