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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701194
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:10:00 PM


Document Has Been Signed on 12/20/2023 03:10 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:HOSPITALITY HOUSEFACILITY NUMBER:
502701194
ADMINISTRATOR:PADILLA, LORRAINEFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 45DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Lorraine Padilla TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with Administrator, Lorraine Padilla and explained the reason for the visit. Census 45. LPA Lund and Administrator Lorraine Padilla toured/inspected the facility. The kitchen was inaccessible to residents and was locked when not staffed. The LPA inspected the food supply and found 2- days of perishable and 7- days of non-perishable groceries present at this time. Fire extinguishers were inspected by Jorgenson Co on May 19, 2023. LPA also observed a sufficient number of smoke/carbon monoxide detectors to be in compliance. First Aid kit was also inspected and found to be in compliance. LPA inspected medications and log/EMAR and found to be in compliance. LPA inspected the exterior of the building. Gates on either side of the facility were observed to be locked from the inside. LPA inspected the Emergency/Disaster kit and found it to be in compliance at this time. LPA conducted a records review of 4 resident files and were in compliance. A review of 3 Staff files and were in compliance. LPA toured the dining room, living room, resident rooms and all common areas had sufficient furniture, furnishings, and lighting at this time, to be in compliance. LPA observed all of the required signage: License, Administrator’s Certification, Personal Rights, Facility Sketch, Emergency Disaster Plan, and Emergency/Resource Numbers. LPA also observed posted menus and activity schedules for residents. LPA observed that all of the bathrooms inspected all contained grab bars and non-skid surfaces in the showers. Paper towels, liquid hand soap dispensers and trash cans with lids were also present in each bathroom. The linen closet was inspected and found a sufficient amount of linens for the residents in care at this time.No deficiencies were observed or cited during today's inspection per California Code of Regulations, Title 22.Exit interview held and copy of the report.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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