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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700962
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:51:51 PM


Document Has Been Signed on 03/21/2024 12:51 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Genaro Baisac JTIME COMPLETED:
01:00 PM
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LPA Jason Lund arrived unannounced to conduct 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/inspected 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 has a Medication cabinet (locked) were medication is stored, in the Medication cabinet the First aid kit was observed with all the 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 reviewed two staff files and two resident files and were in compliance.

No deficiencies were cited on this visit. Exit interview and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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