<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700543
Report Date: 08/04/2022
Date Signed: 08/05/2022 08:56:18 AM

Document Has Been Signed on 08/05/2022 08:56 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:AG ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
502700543
ADMINISTRATOR:NKWOCHA, ONYEMAFACILITY TYPE:
735
ADDRESS:3829 WILD PALMS DRTELEPHONE:
(209) 275-3272
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Oynema Nkwocha TIME COMPLETED:
01:30 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) Arielle Pascua arrived at this facility on 08/04/2022 to conducted an unannounced annual visit. LPA Pascua was greeted by caregiver, Sheriff Kabba and stated the purpose for today's visit. Caregiver, Kabba was asked to call the Facility Designated Administrator to let them know that CCL was present at this time. LPA Pascua shortly met with, Facility Designated Administrator, Oynema Nkwocha. This facility is vendorized by Valley Mountain Regional Center and is a Level 4I home.
Census was currently 4. A tour of this facility was conducted.
Administrator holds current certificate and expires on, 06/24/2023.
The facility has a main entrance COVID screening point. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily.
Fire extinguisher located in the kitchen appeared to have been annually inspected on 04/6/2022 and is weekly inspected by Facility Designated Administrator.
The kitchen area was toured. LPA Pascua observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional freezer located in the garage. Knives and additional cleaning supplies were locked and made inaccessible to the residents at this time.
LPA Pascua observed a locked centralized stored medication cabinet located in the living room. Along with Facility Designated Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. A washer and dryer were also identified in the garage. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: AG ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 502700543
VISIT DATE: 08/04/2022
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
26
27
28
29
30
31
32
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.

A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

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

-LIC 308

-LIC 400

-LIC 500

-LIC 610.

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2