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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700861
Report Date: 09/03/2021
Date Signed: 09/14/2021 02:02:35 PM

Document Has Been Signed on 09/14/2021 02:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SED RESIDENTIALFACILITY NUMBER:
502700861
ADMINISTRATOR:SANCHEZ, DAMARIS VIDOTFACILITY TYPE:
735
ADDRESS:1110 CUSTER COURTTELEPHONE:
(209) 248-7480
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 3DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Salome GarciaTIME COMPLETED:
02:00 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 09/03/2021 by LPA Charlie Yang and was met by the facility designated Administrator, Salome Garcia, who was briefly interviewed.
Current census was 3 residents.
Tour of the facility was conducted. Mitigation plan and binder was reviewed by this LPA.
Kitchen area was toured. Cabinets and drawers were reviewed for adequate plates, glassware, and dinnerware sufficient to meet the needs of the residents at this time.
Food supply was reviewed for 2-day perishable and 7-day nonperishable quantities at all times. Pantry area was reviewed as well.
Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures for medication dispensing, documentation, and control were discussed with the facility designated Administrator.
First aid kit was observed to be present and contained all required components at this time.
A sample of the resident rooms were toured. A tour of the resident restrooms was conducted.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the common rooms was conducted. Living area, dining area, and all other areas intended for resident use were toured.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 05/14/2021 and in compliance at this time.
Laundry area was toured. This LPA observed supplies of hand sanitizers, masks, and other PPEs. Laundry detergents and cleaning agents were observed to be locked and made inaccessible to the residents at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence and side gate was conducted. This LPA observed a shed in the backyard which was opened and toured at this time. It was observed to be used as a storage unit.
There were no deficiencies observed or cited during today's annual visit.
Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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