Community Care Licensing

Document Has Been Signed on 03/09/2023 12:24 PM - It Cannot Be Edited

FACILITY NAME:	ASIANA RESIDENTIAL SERVICES		FACILITY NUMBER:	502700701
ADMINISTRATOR:	KHAN, SAJIDA		FACILITY TYPE:	735
ADDRESS:	5020 TAMARA WAY		TELEPHONE:	(209) 566-3933
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY: 6		CENSUS: 6	DATE:	03/09/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Evangeline Majidi		TIME COMPLETED:	11:58 AM

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

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit. LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited has been cleared. Deficiency cited under Title 22 Regulations has been cleared. Licensee did complied with the terms of the Plan of Correction by POC due date. Section Cited: 80075(k)(5) Date Due: 10/28/2022 Plan of Correction: The Administrator shall submit a plan of how the facility will dispense medications to clients on daily basis. All facility staff who manage, Corrections: Cleared By Visit Clearance Date: 03/09/2023 Exit interview conducted

SUPERVISORS NAME: Stephenie Doub LICENSING EVALUATOR NAME: Albert Johnson LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023