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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700664
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:59:34 PM

Document Has Been Signed on 10/30/2023 02:59 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: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:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Cami Azevedo TIME COMPLETED:
03:15 PM
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Licensing Program Analyst Jason Lund arrived unannounced to conduct annual/required inspection. LPA Lund was met by staff and later with Administrator Cami Azevedo and explained the reason for the visit. Census 4. The facility is licensed for 2 non-ambulatory and 2 ambulatory residents.

LPA Lund & Administrator Cami Azevedo toured/inspected the facility. The clients’ 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 facility has 8 smoke detectors which are all wired together per Stanislaus County Code. Carbon monoxide detector is in working condition. The fire extinguisher was inspected and valid through 6/9/2024. LPA Lund reviewed two clients & two staff files and are in compliance.

No deficiencies were citied, and a copy of the report was left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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