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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700664
Report Date: 11/03/2021
Date Signed: 11/04/2021 08:33:16 AM

Document Has Been Signed on 11/04/2021 08:33 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:HLH-2 CARE HOME INCFACILITY NUMBER:
502700664
ADMINISTRATOR:CAMI J AZEVEDOFACILITY TYPE:
735
ADDRESS:1721 SILVAIRE DRIVETELEPHONE:
(209) 244-3898
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 4CENSUS: 4DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Cami AzevedoTIME COMPLETED:
04:00 PM
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LPA Licensing Program Analyst Jason Lund arrived at the facility unannounced to conduct annual required inspection. LPA Lund explained the reason for the visit to Administrator Cami Azevedo.

The facility will be licensed for 2 Non-ambulatory and 2 Ambulatory residents. The home met all regulation requirements, including wheelchair ramps for non-ambulatory rooms. These rooms contained single action door locks. The rooms were in compliance, well furnished, with all required pieces of furniture. The two non-ambulatory rooms had spring loaded, fireproof doors.

The 2 bathrooms met regulations including handrails, and a non-slip shower mat. The home had 8 smoke detectors which are all wired together per Stanislaus County Code. A carbon monoxide detector was installed. All were tested to ensure were in working condition. The fire extinguisher was inspected and valid through 8/2022.

At the time of the visit no deficiencies were citied and report left
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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