<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701149
Report Date: 03/25/2024
Date Signed: 03/25/2024 12:56:10 PM

Document Has Been Signed on 03/25/2024 12:56 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: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: 56DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator John OrahamTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund arrived announced to conduct an annual/required inspection. LPA met with Administrator John Oraham and explained the reason for the visit. Census: 56

LPA Lund & Administrator John Oraham toured/inspected 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 Lund observed furniture and lighting to be sufficient for the facility. The temperature of the facility at the time of the visit was 75 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 and is in compliance. Facility has central heating and air. LPA observed there is a centrally stored medications area locked and inaccessible to clients. LPA Lund reviewed three staff files & four clients files and is in compliance.

No deficiencies were observed during this visit. Exit interview held, copy of report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1