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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 03:04:17 PM

Document Has Been Signed on 01/22/2024 03:04 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Jessica SanchezTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an case management visit. LPA Lund met with Administrator, Jessica Sanchez and explained the reason for the visit. Census 32.

On 1/16/2024 Community Care Licensing received an Unusual Incident/ Injury Report stating that Client (C1) went AWOL on 1/13/2024. Staff were doing bed check when they noticed that C1 was not in bed. Staff notified conservator and Sheriffs department Case# 524001445. C1 return from the facility around 2225 and stated that did not sign out to go out for a walk. The facility did ½ checks for C1 for a week. C1 LIC602 dated 1/1/2024 stated C1 can leave the facility unassisted.

No deficiencies citied 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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