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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700702
Report Date: 10/30/2025
Date Signed: 10/30/2025 12:29:48 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/30/2025 12:29 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:
10/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Jessica Villasenor, Administrative Team Lead TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/30/2025 LPA Campbell conducted an unannounced annual inspection at this facility. LPA Campbell identified themselves and explained the purpose of the visit. LPA Campbell was met by Administrative Team Lead Jessica Villasenor. LPA Campbell was allowed entry into the facility that is licensed to serve a total capacity of 5 residents. The current census is 5.

LPA Campbell toured the facility with Jessica Villasenor.  The kitchen was accessible to residents and clean and sanitary. The LPA observed 7 days of non-perishable and 2 days of perishable food supplies.  There were enough clean plates, cups and bowls and cutlery to meet capacity. Residents were not present and were in the day program activity room with staff.

Fire extinguishers inspected were charged on 12/06/2024 by A.R.F. Fire. The dual smoke and carbon monoxide detector is connected to the Fire Department. LPA Campbell therefore examined fire drill logs. Records show that fire drills are conducted one time a month. There was enough lighting in all common areas, resident rooms, and hallways. LPA Campbell requested to observe the first aid kit and observed that there were manual, tweezers, scissors, gauze and Band-Aids present in the kit as well as a first aid guide and thermometer.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 10/30/2025
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 LPA Campbell reviewed 4 resident staff files during this visit.  All required documentation was complete. Medication was centrally stored and secured. The medication administration record (MAR) was reviewed and found to be complete with accurate documentation of administered medications provided to residents.

The laundry room was locked and detergents and softener were also secured inside of the rooms. Cleaning products in the locked closet and knives in locked drawers were also inaccessible to residents. Client rooms contained appropriate furnishings such as a bed, drawers, linens, a night table and lighting.

LPA Campbell observed the outside area of the facility to be clean and free of hazards. There was a shaded area in the front for residents to enjoy.  Fencing was in good repair. There were no bodies of water present. The facility common area was clean and free of obstruction.  The temperature reading was 76 degrees Fahrenheit per Title 22 regulations. Per the Administrative Team Lead, residents have control of the thermostat and may turn it off.
LPA Campbell requested the following annual documents for the facility file: LIC 308 Designation of Responsibility, Copy of Liability Insurance.

In the administrative office, emergency food and water is stored, an ombudsman poster was sighted and cleaning supples were identifed in a locked maintenance cabinet.
Per California Code of Regulations (CCR) - Title 22, 0 deficiencies are being cited. An exit interview was held, and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
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