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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700702
Report Date: 12/04/2023
Date Signed: 12/07/2023 07:53:39 AM

Document Has Been Signed on 12/07/2023 07:53 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PAULSON COMMUNITY- SIERRA HOME, THEFACILITY NUMBER:
502700702
ADMINISTRATOR:HEKIMIAN, ARENFACILITY TYPE:
735
ADDRESS:2806 PAULSON RDTELEPHONE:
(559) 228-3056
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 5CENSUS: 5DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Steven Jackson, Clinical Team LeadTIME COMPLETED:
01:30 PM
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On 12-04-23, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit at this facility at approximately 9:30 am to conduct an annual inspection. LPA Campbell met with Steven Jackson, Clinical Team Lead (CTL) and explained the purpose of the visit. Facility contact information for the facility and administrator were verified.

LPA Campbell toured and observed the physical plant to ensure compliance with Title 22 regulations. Each facility is licensed for five non-ambulatory residents and has a Fire Access Control Panel (FACP) to communicate with the Fire Department and manage fire response. The facility is approved for delayed egress. Upon entry, LPA observed a kitchen, furnished common area, laundry room, employee/med office and IT closet for cable and internet access. Floor pathways were clear of obstruction. LPA Campbell observed bedrooms for residents that contained drawers, a closet, a chair and night table. Each resident also has their own bathroom as well as a bed and mattress with a water proof mattress cover.

Sharps were observed to be locked in the facility kitchen. The refrigerator temperature was observed at 39 degrees Fahrenheit and the freezer temperature was observed at 0 degrees Fahrenheit. Enough perishable and non-perishable foods were available for residents and staff either in the resident kitchen or in the program building 50 feet away from the residential building. The hot water temperature for bathrooms in the residential building was observed to be 110.8 degrees Fahrenheit. The thermostat was set at 68 degrees Fahrenheit and the fire extinguisher was last checked on 11/03/2023.

LPA Campbell observed residents medication and reviewed the MAR. First Aid Kits were found to be present and cleaning products were locked away, inaccessible to residents either in the laundry room or storage closet. In the same cabinet, LPA Campbell observed the flashlight and batteries in case of loss of power. Of the 34 staff and 5 residents for this facility, LPA Campbell reviewed three staff files and 1 resident file selected randomly.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PAULSON COMMUNITY- SIERRA HOME, THE
FACILITY NUMBER: 502700702
VISIT DATE: 12/04/2023
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Based on observation, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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