507001000-4-24-2023-27-AS-KVIA-CR7V87-20230424161216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507001000
Report Date: 03/29/2023
Date Signed: 04/24/2023 04:13:05 PM

Document Has Been Signed on 04/24/2023 04:13 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	DAVIS GUEST HOME #3		FACILITY NUMBER:	507001000
ADMINISTRATOR:	HEATHER MCCLOSKY		FACILITY TYPE:	740
ADDRESS:	1628 NADINE AVENUE		TELEPHONE:	(209) 538-1346
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	10	CENSUS: 10	DATE:	03/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Heather McClosky		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/29/2023 an unannounced annual inspection was conducted by Licensing Program Analysts, (LPAs), Kimberly Viarella and Charlie Yang to Davis Guest Home #3. LPAs identified themselves and the purpose of their visit to the designated facility administrator, Heather McClosky. (Administrator Certification expires on 09/28/2023) and in compliance at this time. A brief interview was conducted with the facility designated Administrator. Census was 10 residents at this time. There were no hospice or bedridden residents at this facility. LPAs toured the interior and exterior of the facility including but not limited to the living room, kitchen/dining area, bathrooms, resident bedrooms, food storage areas and backyard. The designated facility administrator began the tour with the exterior, unlocking each storage shed. Laundry facilities were observed in one shed and non-perishable food items in another, A third shed contained a lawn mower and other storage items. There were no bodies of water present. There was a picnic table and sitting area for residents. LPAs did not witness any holes or missing planks in the fence. Two bathrooms were inspected, Each bathroom had hand soap and paper towel towel dispensers. Grab bars and non-skid surfaces were observed at this time. The hot water temperature was measured and found to be 108 degrees Fahrenheit. LPAs observed 3 fire extinguishers on the premises: 1 in the living room and 2 in the kitchen. All were inspected on 08/15/2023. LPAs observed smoke and carbon monoxide detectors throughout the facility as required. Resident bedrooms were inspected and enough furniture, furnishings, and lighting were observed to be in compliance at this time. Linen closets also contained enough supplies to accommodate the needs of the residents in care at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS GUEST HOME #3	FACILITY NUMBER: 507001000
	VISIT DATE: 03/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The kitchen area was also inspected and sharps were observed to be stored in a locked drawer. The food supply was checked. LPAs observed enough perishable food items for 2 days and enough non-perishable food items for 7 days. Menus, along with a calendar of activities for residents, were also seen posted in the kitchen area.

Medications were centrally stored in a locked medication cart in the kitchen. Procedures and policies regarding storing, tracking and dispensing were reviewed with the designated facility administrator. The medication destruction log was also reviewed. The first aid kit was stored in the staff office and LPAs found it to be complete with all the required items present.

Files were reviewed for 5 residents and 5 staff members of this facility. All required documents were included.

No deficiencies were cited or observed at this time.

The following documents were requested to be updated and submitted to Community Care Licensing:

LIC 308
LIC 400
LIC 500
LIC 610
Copy of the Liability Insurance

An exit interview was conducted with the designated facility administrator and a copy of this report was presented.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2