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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701221
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:28:28 PM

Document Has Been Signed on 02/15/2024 02:28 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:PAULSON COMMUNITY - SEQUOIA HOME, THEFACILITY NUMBER:
502701221
ADMINISTRATOR:HEKIMIAN, VARTANFACILITY TYPE:
735
ADDRESS:2812 PAULSON RD.TELEPHONE:
(559) 577-4239
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 4CENSUS: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Villasenor, Team Program LeadTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced visit on 02/15/24 at 9:30 AM. LPA Campbell met with Jessica Villasenor, Team Program Lead and Administrator Vartan Hekimian and stated the purpose of the visit. This facility is licensed for 4 ambulatory residents. Bedroom #4 has been reserved for 1 non-ambulatory resident. The facility is approved for delayed egress with a secured perimeter.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. There was an unlocked pantry for ease of access for residents per the Team Program Lead. The hot water temperature was measured in the bathroom. The resident bathroom water temperature measured at 122 degrees, 2 degrees over the required range of 105 and 120 degrees. The facility thermostat was observed at 71 degrees Fahrenheit which is within the required range of 68 and 85 degrees. Each resident may also control the temperature in their individual room. Medication was in the staff room and was found to be locked away and inaccessible to residents. LPA Campbell observed the MAR for the facility which was found to be complete. The first aid kit was observed in the staff office.

LPA Campbell requested client and staff files for review. LPA reviewed 3 of 4 resident files and 3 of 36 staff files. Resident and staff files were complete. Toxins are stored in the laundry room and in a storage closet under lock and key. Residents may wash their own laundry during scheduled times. Detergent is dispersed as needed and returned to the locked cabinet. Otherwise, the laundry room and storage closet is locked.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PAULSON COMMUNITY - SEQUOIA HOME, THE
FACILITY NUMBER: 502701221
VISIT DATE: 02/15/2024
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LPA Campbell requested and received the most recent staff roster, Personnel Report, a copy of the Administrator Certificate and Emergency Disaster Plan.

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2