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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001000
Report Date: 02/07/2024
Date Signed: 02/07/2024 05:00:12 PM


Document Has Been Signed on 02/07/2024 05:00 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:DAVIS GUEST HOME #3FACILITY NUMBER:
507001000
ADMINISTRATOR:HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:1628 NADINE AVENUETELEPHONE:
(209) 538-1346
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:10CENSUS: 8DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Heather McClosky, AdministratorTIME COMPLETED:
05:15 PM
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On 02/07/2024, Licensing Program Analyst (LPA) Renee Campbell arrived for an unannounced visit to conduct an annual inspection visit. LPA Campbell met with Heather McClosky, Administrator and explained the purpose of the visit.

The facility is licensed for 10 ambulatory residents, 60 and over. There are eight residents currently in the facility. Another two residents are in the community. Residents were observed performing various activities throughout the facility by LPA. LPA Campbell toured and inspected the physical plant inside and outside. There are three sheds in the backyard for storage and a washer and dryer. All sheds were locked. LPA observed an outside lounge area with a soda machine, table and benches. The kitchen contained a dining room, cabinets and a locked sharps drawer. Perishable foods were observed with enough items to sustain the residents for two days. There were also enough non-perishable foods to last the residents for seven days. Bathrooms, bedrooms and common areas were toured and found to contain the required accessories for compliance.


The bathroom water temperature was measured at 107 degrees Fahrenheit which is required to be not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The thermostat was set at 72 degrees. LPA Campbell observed the facility first-aid kit contained scissors, tweezers and thermometers along with bandages and first-aid manuals. Toxins and cleaning products were kept locked in storage closets. The fire extinguisher was last inspected on August 8th, 2023. Smoke alarms and Carbon Monoxide alarms were tested successfully. Of the 10 staff, 2 staff files were reviewed. No bodies of water were present.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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