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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700543
Report Date: 09/27/2023
Date Signed: 09/27/2023 01:25:45 PM

Document Has Been Signed on 09/27/2023 01:25 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: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:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Augusta Nkwocha TIME COMPLETED:
01:30 PM
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On 09/27/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by Staff Member, Isabel Jimenez and explained the purpose of the visit. LPA asked that SM Jimenez call the Facility Designated Administrator to inform them that CCL was present at this time. At 11:30am, LPA met with Licensee Augusta Nkwocha and FDA Onyema Nkwocha and explained the purpose of the visit. There was one other staff member present at this time, Sheriff Kabba.
Current census was 4. 2 out 4 residents were out at their respective day program.
This facility is licensed to serve 4 residents, of which all my be non-ambulatory. This facility is also vendorized by Valley Mountain Regional Center to serve and retain Level 4I residents at this time.
The Facility Designated Administrator does not have an active current administrator certificate at this time, however, has sent in the necessary documents for renewal before the expiration date and is awaiting for the department at this time.
LPA reviewed 4 resident files and 4 staff files all of which were current and up to date.
Fire extinguisher located in the kitchen appeared to have been annually inspected on 04/26/2023 by the local fire company, Fire Code 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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: 09/27/2023
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A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.

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: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
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