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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001000
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:14:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/05/2021 01:14 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 8CENSUS: 9DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Nicholas DuarteTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Nicholas and explained the purpose of the visit. Later joined by Heather McClosky.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 111 degrees Fahrenheit in client's bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. The facility is operating over it's license capacity of eight (8). There are ten (10) residents in care.

LPA reviewed 5 resident and 2 staff files, including criminal record clearances. First aid kit was checked and is complete. Fire drill was conducted on 11/01/2021.

Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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Document Has Been Signed on 11/05/2021 01:14 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/05/2021 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS GUEST HOME #3
FACILITY NUMBER: 507001000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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Licensee agrees to ensure they are not over their approved fire clearance going forward. Licensee further agrees to submit an updated LIC 200, facility sketch, and letter to CCL requesting a capacity change if they wish to increase their approved capacity. Until an approved fire clearance is granted the facility shall not have
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LPA observed and reviewed 10 Client files. The facility is licensed for 8. This poses an immediate health and safety risk to clients in care.
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More than eight (8) clients at a time. Letter of understanding due to CCL by 11/6/2021. If an increase is requested documents shall be sent to CCL as soon as possible.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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