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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701371
Report Date: 05/24/2024
Date Signed: 05/24/2024 03:11:26 PM

Document Has Been Signed on 05/24/2024 03:11 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:WE ARE THE VILLAGE LLCFACILITY NUMBER:
502701371
ADMINISTRATOR/
DIRECTOR:
GONZALEZ, LATRICEFACILITY TYPE:
735
ADDRESS:2205 SUNNY ISLAND CTTELEPHONE:
(209) 271-2912
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 0DATE:
05/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Latrice Gonzalez TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/24/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to conduct a pre-licensing visit. LPA met with applicant, Latrice Gonzalez and explained the purpose of the visit. The purpose of this visit was to conduct a pre-licensing visit.

This facility is intended to serve and retain residents from Valley Mountain Regional Center. This facility is awaiting vendorization from VMRC to retain Level 3 residents at this time. This facility must also hold 6 ambulatory residents.

Current census was 0. A brief interview with applicant Gonzalez was conducted.
LPA conducted a tour of the kitchen, living area, and dining area. LPA reviewed food storage which showed a sufficient amount of 2-day perishable and 7 day non-perishable food supply at this time.
Knives were present on top of the counter and made accessible. LPA discussed with the applicant the location in which knives would be locked. LPA was shown a lock that would be used with the drawer.
Furniture and furnishings in the living area were sufficient to meet resident needs.

A tour of the backyard was conducted. Perimeter gate was in good repair. Exit gate was observed to be in good repair. Resident furniture for seating was observed and well maintained.

A tour of the garage was conducted. Supplies were observed. LPA observed and was shown a generator purchased. LPA advised that generator shall be charged and ready for any emergency purposes.
LPA also observed fire extinguishers which were purchases on 08/29/2023.

A tour of a downstairs bathroom was conducted. Hot water was measured to ensure it was within 105-120 degrees.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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: WE ARE THE VILLAGE LLC
FACILITY NUMBER: 502701371
VISIT DATE: 05/24/2024
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A tour of second level of the facility was conducted. The second level holds 3 resident bedrooms, 1 staff bedroom, laundry room, and 1 bathroom.

LPA toured laundry room. Washer and Dryer were identified.
LPA toured resident bedroom #1. A locked refrigerator and cabinet were identified and was stated by the applicant that it would house resident medication. LPA advised that the medication cabinet should be an a common area and not in a resident bedroom. An adjacent bathroom was toured. It was observed that this resident bedroom had a bed, bed frame, closet space, side drawer and lamp.

LPA toured resident bedroom's #2 and #3. It was observed that personal belongings were present at this time. It was observed that resident bedrooms had a bed, bed frame, closet space, side drawer, and lamp.

LPA toured staff bedroom.

Smoke alarms and carbon monoxide detectors were tested and in good repair.

It was advised that the facility must be resident ready and all bedrooms must show the that sufficient furniture highlight in Section 85088 is present and applicant must remove personal belongings from intended bedrooms for resident use. In addition, locks for knives, toxins, laundry supplies, cleaning supplies and medication must be installed to show inaccessibility.

Based on the observations made during the course of this visit, the applicant has not passed this pre-licensing visit.

This Pre-Licensing is incomplete with deficiencies to be resolved. A follow up Pre-licensure visit will be conducted upon resolution of deficiencies.

An exit interview was conducted and a copy of this report was provided to the applicant at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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