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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700664
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:48:28 PM

Document Has Been Signed on 03/28/2024 02:48 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Cami AzevedoTIME COMPLETED:
03:15 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 Jason Lund arrived unannounced to conduct Case management visit. LPA Lund was met Administrator Cami Azevedo and explained the reason for the visit. Census 4.

LPA Lund received an Unusual Incident Report (UIR) dated 3/18/2024 regarding Client (C1) refusing medication. The client refused three days of C1’s medications and the facility set an appointment with C1’s doctor to see what options C1 has with his medication’s refusal. C1 had an IDT (Emergency) meeting with Valley Mountain Reginal Center Service Coordinator, staff and C1. C1 made some agreements with staff and C1’s Service Coordinator. The facility will continue to do UIR’s if C1 is refusing C1’s medication.

No deficiencies were citied, and a copy of the report was left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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 1