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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701371
Report Date: 07/15/2024
Date Signed: 07/16/2024 08:13:42 AM

Document Has Been Signed on 07/16/2024 08:13 AM - 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:
07/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Latrice GonzalezTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 07/15/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to conduct a reinspection pre-licensing inspection. LPA met with applicant, Latrice Gonzalez and explained the purpose of the visit.
This facility is intended to serve and retain residents from Valley Mountain Regional Center. This facility does not have vendorization from VMRC to retain Level 3 residents at this time. This facility must also hold 6 ambulatory residents.
The purpose of this visit was to re-inspect resident bedrooms to reflect that the facility is move in ready for residents in care, in addition, all knives, toxins, laundry supplies, cleaning supplies, and medication was to be locked and made inaccessible to residents in care.
A tour of the physical plant was conducted. The following items were observed by the LPA during this visit.
A tour of the kitchen area was conducted. There is one locked cabinet that houses knives and is made inaccessible to residents in care. The cabinet under the sink is locked with cleaning supplies and is made inaccessible to residents in care. LPA observed an open drawer and observed a pair of scissors accessible to residents in care. A tour of food supply was conducted. LPA observed items such as an open box of Famous Amos cookies, trail mix, frosted flakes, ritz crackers, cheez it's, open bags of chips, an open pack of water, mayonnaise, honey, mustard, boxed pastas, oats, peanut butter, potatoes, and assorted canned items. A tour of the refrigerator was conducted. LPA observed a pack of eggs, orange juice, cut up watermelon, cran-mango juice that is half full, probiotic drinks, a jar of salsa that has been consumed and almost empty.
Living area and dining area was toured. LPA observed two white pet bed with housing attached, an office space with a computer and other office supplies. A large couch was identified. A tv was also identified with remotes attached.
A tour of the garage was conducted. It was observed that this applicant will be using this space as an additional storage area. LPA observed around 8-10 black garbage bags of items, other items such as chairs, pet items, emergency food storage and fire extinguisher was identified. Cleaning supplies were made available such as laundry detergent, raid, clorox and lysol wipes.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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: WE ARE THE VILLAGE LLC
FACILITY NUMBER: 502701371
VISIT DATE: 07/15/2024
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LPA advised that the garage area can also be an area where residents can enter. Fire extinguisher had a receipt from Amazon with purchase date of 10/29/2023.
A tour of the bathroom was conducted. Hot water temperature was taken to ensure it was within 105-120 degrees.
A downstairs closet was identified. LPA observed, varies coats, paintings, bags, books, luggage, and cleaning items.
A tour of 3 resident bedrooms and one staff bedroom was conducted. All rooms were equipped to have locking mechanisms. In the staff bedroom, LPA observed a laptop, with a printer, and tv.
LPA observed 3 cabinets next to the stairway. Two cabinets were locked. Of these two cabinets housed kids nyquil, opened medication, and other first aid items, drano, lysol wipes, scissors, q-tips and other items were identified in the first locked cabinet. In the second cabinet, LPA observed a dirt devil, and other house supplies. In a third cabinet, LPA observed 3 blankets and 3 bedsheets.
A tour of a shared bedroom was conducted. LPA observed a queen sized bed perpendicular to another resident bed with a side table in the middle. One large chest drawer was identified. two chairs were observe with a small desk attached. A tour of the attached bathroom was conducted. LPA observed comet, cleaning supplies, and nasal spray locked and made inaccessible.
Laundry area was toured, LPA observed cabinets with wash cloths, and towels. Laundry soap and other cleaning supplies were locked and made inaccessible.
A tour of the 2nd resident bedroom was conducted. LPA observed decorative purple flowers hanging on the ceiling, a bean bag, and a chalk wall with astrological writing on it. A moon shaped shelf was also present. LPA observed a desk, a chair and a tv also equipped in this room.
A tour of the 3rd resident bedroom was conducted with a poster that states, "Danger, Shark Zone." LPA observed a large bed with shark bedding a blue wall with blue fish wrapped around and a shark rug. Multiple drawers were identified as well as a fan and desk with a chair.
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: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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