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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700962
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:18:07 PM


Document Has Been Signed on 03/25/2022 03:18 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: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: 3DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Genaro Baisac JR.TIME COMPLETED:
03:30 PM
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LPA Jason Lund arrived at the above facility unannounced to conduct na post-licensing & annual required visit. LPA Lund explained the reason for the visits to administrator Genaro Baisac Jr. Census: 3
LPA Lund & administrator Genaro Baisac Jr toured the facility, 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 is 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 for use by the residents were observed to meet the needs of the residents at this time. The Facility also had a staff bedroom which 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 and carbon monoxide are in compliance at this time.
LPA Lund spoke with Administrator Genaro Baisac regarding the COVID 19 for staff & visitors.
As a result of this visit, no deficiencies were cited at this time. Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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