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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701149
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:21:58 PM

Document Has Been Signed on 03/25/2022 12:21 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:CENTRAL VALLEY ADULT CARE, LLCFACILITY NUMBER:
502701149
ADMINISTRATOR:ORAHAM, JOHNFACILITY TYPE:
775
ADDRESS:1208 FLOYD AVE BLDG ATELEPHONE:
(847) 708-5175
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 90CENSUS: 0DATE:
03/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John OrahamTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived announced to conduct a Pre-licensing inspection. The facility is licensed to serve a capacity of 90 clients.

LPA was allowed entry into the Day program. LPA met with John Oraham Applicant. LPA observed that there are no clients at this time. LPA, and Applicant toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The Facility has a large open space for clients to participate in cinema movies, music, fitness, gaming, and technology. There are four other rooms, quiet room, sensory, nutrition and self-care room. The client has lockers to store their belongs, staff have a break room, administrator office and reception office.

LPA observed furniture and lighting to be sufficient for the facility. The temperature of the facility at the time of the visit was 70 degrees. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Facility has central heating and air. LPA observed there is a centrally stored medications area locked and inaccessible to clients.

LPA conducted the Component III during this visit. License pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
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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