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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700861
Report Date: 09/14/2023
Date Signed: 09/19/2023 11:05:09 AM

Document Has Been Signed on 09/19/2023 11:05 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 AC/SC, 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: 4DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Damaris Vidot SanchezTIME COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 09/14/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Damaris Vidot. The co-Licensee, Salome Garcia Williams arrived shortly thereafter to this facility while this LPA was conducting this annual visit. Brief interview was conducted with both facility designated Administrators at this time.
Current census was 4 residents. It was learned that all (4) residents were out of the home at their respectable day programs at this time. This facility is vendorized to accept and retain Level 4E residents through Valley Mountain Regional Center.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Damaris Vidot. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 02/05/2023.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe an additional food storage unit which was present and functional at this time in the designated staff room.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SED RESIDENTIAL
FACILITY NUMBER: 502700861
VISIT DATE: 09/14/2023
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linens to meet the needs of the residents at this time.
Garage area was toured. This area has been converted as a recreation room to house additional furniture and supplies for the facility residents.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located in facility living area and recreation room, were observed to have been annually inspected on 05/09/2023 by the local fire extinguisher company, Jorgensen Co, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
It was observed that there was a shed present on facility grounds at this time. Decorations and additional maintenance supplies were observed to be present while this shed was locked and made inaccessible to the residents at this time.
A review of (4) facility resident records was conducted.
A review of (4) facility staff records was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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