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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001131
Report Date: 01/22/2024
Date Signed: 01/22/2024 02:29:52 PM

Document Has Been Signed on 01/22/2024 02:29 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 IVFACILITY NUMBER:
507001131
ADMINISTRATOR:JESSICA SANCHEZFACILITY TYPE:
735
ADDRESS:1552 OHIO AVENUETELEPHONE:
(209) 549-0772
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY: 34CENSUS: 32DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Jessica SanchezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with Administrator, Jessica Sanchez and explained the reason for the visit. Census 32.
Fire extinguishers were last inspected on 08/7/2023.
LPA Lund & Administrator Jessica Sanchez toured five of the clients bedrooms and were found to contain furnishings and lighting to be in compliance at this time. 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 LPA found that all sharps were secured in a locked drawer. Clients 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. 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. Clients’ medications and logs were stored in the main office off the main entrance. All clients medications were stored in a locked medication cart and were observed to be in compliance at this time. LPA Lund reviewed three clients files and three staff files and were in compliance at this time.
There were no deficiencies observed during visit. Exit interview and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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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