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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700702
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:00:09 PM

Document Has Been Signed on 12/05/2024 03:00 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:PAULSON COMMUNITY- SIERRA HOME, THEFACILITY NUMBER:
502700702
ADMINISTRATOR/
DIRECTOR:
HEKIMIAN, ARENFACILITY TYPE:
735
ADDRESS:2806 PAULSON RDTELEPHONE:
(559) 228-3056
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 5CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jessica Villasenor, Team Lead';TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing program Analyst (LPA) Renee Campbell conducted an unannounced annual required visit at the above Facility on 12/05/2024. LPA Campbell met with Team Lead, Jessica Villasenor and toured the facility inside and outside. Residents of the facility were in program, leaving the facility empty.

The facility is licensed to serve developmentally disabled adults ages 18 to 59 and approved for delayed egress. The facility has 1 common area, Staff office, a staff bathroom and 5 resident rooms with a bathroom in each. There is a meeting area, dining area, computer area and a laundry area. There are client bathrooms with grab bars, paper towels and soap. There are cameras on the outside of the building.

The Facility has a kitchen area with a sink, refrigerator and food pantry. Locked sharps drawers were observed in the kitchen area. LPA Campbell observed enough perishables to last 2 days and enough non-perishables to last 7 days. Dining plates and utensils were observed in the kitchen cabinets. The refrigerator temperature was 35 degrees Fahrenheit and the freezer temperature was set at 0 degrees Fahrenheit. LPA Campbell observed the first aid kit in the staff room as complete with scissors, tweezers and thermometer . The required items could not be immediately. LPA Campbell suggests that staff be assigned weekly organization checks for the for all facilities so that all items are medical tools can be located regardless of where staff is working.

Of the 30 staff working at the facility, 4 files were reviewed. All 4 staff were found to be fingerprint cleared and associated to the facility and their files complete. There were 4 client files that were reviewed as well. Exit interview held with the Team Lead and a copy of report was given at the conclusion of the visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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