507001000-3-27-2025-27-AS-RCAL-DF6Q4Z-20250327115109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507001000
Report Date: 03/27/2025
Date Signed: 03/27/2025 11:52:20 AM

Document Has Been Signed on 03/27/2025 11:52 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:	DAVIS GUEST HOME #3		FACILITY NUMBER:	507001000
ADMINISTRATOR/ DIRECTOR:	HEATHER MCCLOSKY		FACILITY TYPE:	740
ADDRESS:	1628 NADINE AVENUE		TELEPHONE:	(209) 538-1346
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY: 10	TOTAL ENROLLED CHILDREN: 0	CENSUS: 10	DATE:	03/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Heather McClosky, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 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 03/27/25, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to the facility regarding an annual inspection. LPA Campbell met with Administrator McClosky and explained the purpose of the visit. The facility is a single story residence licensed to serve 10 ambulatory clients over the age of 60. There are five bedrooms and two bathroom in all. Upon entry, LPA Campbell observed a well lit hallway leading to facility office. During the visit, LPA Campbell observed four clients present in the facility eating a snack, smoking outside and conducting a phone call. LPA Campbell spoke to two of the clients regarding a stray chicken that had entered the facility backyard and regarding a trip to the store. LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas to ensure there are no safety hazards for residents. Furniture and furnishings were sufficient to meet the needs of residents. The living room common area was clear of obstacles and contained a television as well as plentiful seating. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees.

Lisa Rios	TELEPHONE: (916) 969-9685
Renee Campbell	TELEPHONE: (916) 206-6380
	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: DAVIS GUEST HOME #3	FACILITY NUMBER: 507001000
	VISIT DATE: 03/27/2025

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The backyard was toured by LPA Campbell and pathways and exits were found to be clear. A soda machine was observed in the backyard seating area as well. In the backyard two sheds were accessed and LPA Campbell observed client storage and where the facility washer and dryer are kept along with additional freezers..

LPA Campbell observed first aid supplies (containing tweezer, scissors and thermometers) and a fully-charged and up-to-date fire extinguisher that was last inspected on 08/01/2024. There was a general fire extinguisher for the facility and an ansul extinguisher for the kitchen. Carbon monoxide/smoke detectors were tested and found to be functioning correctly. LPA Campbell observed a minimum 2-day supply of perishable foods in the refrigerator and a minimum 7-day supply of nonperishable food in the cabinets and freezers. LPA Campbell observed locked cabinets for the storage of medication, knives and cleaning solutions

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Heather McClosky and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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