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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701194
Report Date: 03/25/2024
Date Signed: 03/25/2024 02:57:00 PM


Document Has Been Signed on 03/25/2024 02:57 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: 47DATE:
03/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Resident Care Director, Sabrina Duarte 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 Resident Care Director, Sabrina Duarte and explained the reason for the visit. Census 47

LPA Lund received an Unusual/Incident Injury Report from the facility on 3/21/2024 two Residents (R1 & R2) got into a confrontation. The facility notified Stanislaus County Sheriff’s Department Case #S24009369. The facility is having a meeting with ombudsman on 3/26/2024 and the facility is working with both residents since the incident to prevent any further altercations.

No deficiencies were observed or cited during today's visit. 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: 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)
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