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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001131
Report Date: 02/24/2023
Date Signed: 02/28/2023 01:11:45 PM

Document Has Been Signed on 02/28/2023 01:11 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 IVFACILITY NUMBER:
507001131
ADMINISTRATOR:JESSICA SANCHEZFACILITY TYPE:
735
ADDRESS:1552 OHIO AVENUETELEPHONE:
(209) 549-0772
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY: 34CENSUS: 34DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica SanchezTIME COMPLETED:
12:30 PM
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Unannounced annual visit conducted on 02/24/2023 by Licensing Program Analysts, (LPAs) Kimberly Viarella and Charlie Yang, who were met by substitute House Manager, Christopher Hernandez. LPAs informed Christopher of the purpose of their visit and to notify the designated Administrator, Jessica Sanchez, of their presence at the facility. He was interviewed briefly. Jessica Sanchez and Heather McClosky, the designated administrator for Davis Guest House V, led the LPAs on a tour of the facility.
Census at this time was 34.
Fire extinguishers were last inspected on 08/15/2022.
The designated Administrator Certificate for Jessica Sanchez, #6047787735 was recently updated and will expire on 1/26/2024.
LPAs observed that all resident medications and logs were stored in the main office off the main entrance. All resident medications were stored in a locked medication cart and were observed to be in compliance at this time.
A sample of resident bedrooms was reviewed and all were found to contain furnishings and lighting to be in compliance at this time.
It was observed that the laundry room was kept locked and accessed only by staff thus keeping toxic chemicals secured and away from residents.
Bathrooms were inspected and observed to be sanitary and free from toxic chemicals.
The water temperature was measured and observed to be in compliance as it registered between 105 and 120 degrees.
The kitchen area was toured and LPAs found that all sharps were secured in a locked drawer. Residents do not have access to the kitchen and it was kept locked when staff were not present.
It was observed at this time that the majority of food supplies were stored in a separate building with a pantry, with a commercial refrigerator and freezer. There was an adequate supply of 7 day non-perishable and 2 day perishables at this time.
The exterior grounds of the facility were inspected.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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 IV
FACILITY NUMBER: 507001131
VISIT DATE: 02/24/2023
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There was an in-ground pool with the required locked fence surrounding it and it was observed to be in compliance.
There were also two changing rooms adjacent to a locked shed that contained toxic chemicals, holiday storage and other storage items.
The property is surrounded by a chain link fence that is in compliance at this time.
All window screens were observed to be good repair at this time.

The following forms and documents were requested to be updated and submitted into Community Care Licensing for review by this LPA.

LIC 308

LIC 400

LIC 500

LIC 610


There were no deficiencies observed or cited during this annual visit at this time.

Exit interview.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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