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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700861
Report Date: 11/01/2024
Date Signed: 11/01/2024 11:57:37 AM

Document Has Been Signed on 11/01/2024 11:57 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:SED RESIDENTIALFACILITY NUMBER:
502700861
ADMINISTRATOR/
DIRECTOR:
MONTES, BRANDIEFACILITY TYPE:
735
ADDRESS:1110 CUSTER COURTTELEPHONE:
(209) 248-7480
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:SANCHEZ, DAMARIS VIDOTTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. Upon ringing the doorbell, Administrator Damaris Sanchez opened the window beside the door and asked LPA Campbell "can you wait a sec". LPA Campbell asked to be let in to wait since the administrator was right beside the door. The administrator did not comply, and again asked the LPA to "can you wait a sec?" and disappeared from the window. LPA Campbell then waited several minutes at the door and heard movement inside the facility. When the administrator opened the door, LPA Campbell observed the living room and kitchen without debris and one client standing quietly in the hallway. LPA Campbell then met with the Administrator and explained the purpose of the visit.

During the visit, LPA Campbell observed one client who was preparing to take her medication. Another client was reported to still be sleeping after having a Halloween party the night before. Administrator Sanchez also directed LPA Campbell's attention to a picture of one of the clients dressed as the Little Mermaid for Halloween. 

LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas to ensure there are no safety hazards for residents. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 65 degrees Fahrenheit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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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: SED RESIDENTIAL
FACILITY NUMBER: 502700861
VISIT DATE: 11/01/2024
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The facility's water temperature was measured at 115 degrees Fahrenheit in the kitchen and 111 degrees in the resident bathroom, which is within the required range of 105 and 120 degrees Fahrenheit
.
The backyard was toured by LPA Campbell the administrator and pathways and exits were found to be clear. A shed in the backyard was observed to be locked. At LPA Campbell's request, the administrator unlocked it. LPA Campbell observed holiday directions, boxes, a broom and a shovel. The administrator stated that the area was used for client storage.

Of the four residents, LPA Campbell review all four of their files. Of the six staff, all six of their files were reviewed and found to be complete. There are two staff with administrator certificates and both are in compliance and have not expired.

LPA Campbell observed first aid supplies contained scissors, tweezers and a thermometer. Knives were locked in a drawer in the kitchen. There were two fully-charged fire extinguishers that were observed to have been last inspected on May 6, 2024. After testing, carbon monoxide/smoke detectors were found to be functional. LPA Campbell observed a minimum 2-day supply of perishable food in the refrigerator and a minimum 7-day supply of nonperishable food in the cabinets. LPA Campbell observed locked closets and cabinets for the storage of medication. In the locked staff bathroom, LPA Campbell observed storage areas for cleaning solutions as well.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted with Damaris Sanchez and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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