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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700962
Report Date: 03/18/2021
Date Signed: 03/18/2021 09:02:23 PM

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:VALLEY HOME ROYALE CAREFACILITY NUMBER:
502700962
ADMINISTRATOR:BAISAC, GENARO R. JR.FACILITY TYPE:
740
ADDRESS:2809 YUKON DR.TELEPHONE:
(209) 345-4351
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 0DATE:
03/18/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Genaro Baisac Jr.TIME COMPLETED:
03:00 PM
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Announced prelicensing visit was made by LPA Jason Lund via Zoom on 3/18/2021 with applicant, Genaro Baisac Jr.

The facility will be licensed to serve up to (6) residents at any given time. This Applicant is seeking a facility with six nonambulatory residents. There were no residents in care during today's zoom visit.

Tour of the facility was conducted via Zoom. LPA toured the dining area, living area, and all other areas intended for client use. LPA observed to be furnished and maintained in compliance at this time.

The Facility had a Medication cabinet (locked) were medication will be stored. First aid kit was observed in the Medication cabinet to be present and contained all required components at this time.

A tour of the (3) resident bedrooms, was conducted. Furnishings intended for use by the residents were observed to meet the needs of the residents at this time. The Facility also had an staff bedroom witch was a master bedroom. The facility also had one bathroom for the residents.

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. The facility has two fire extinguishers that expire on 3/10/2022 and had a working telephone.
This facility has been found to be in compliance at this time.

Genaro Baisac Jr. completed the Component 111 requirements and Mitigation Plan.
Report will be emailed for signature and emailed back to LPA Lund
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021
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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