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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001176
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:19:58 PM

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:VALLEY COMFORT #5FACILITY NUMBER:
507001176
ADMINISTRATOR:GAITHER,CHRISTOPHERFACILITY TYPE:
740
ADDRESS:2809 LOU ANN DRIVETELEPHONE:
(209) 544-8676
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:92CENSUS: 61DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Nick Gaither TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Jason Lund and Sarah Hurt conducted an unannounced annual required visit. LPAs met with Administrator, Nick Gaither and explained the purpose of the visit.

LPAs walked and Administrator Nick Gaither walk physical plant including assisted living unit, memory care unit, resident bedrooms, resident bathrooms, medication room, medication cart, dining area, kitchen, laundry room and outside perimeter of the care community. LPAs observed the common areas of the community to be free of odor and clean. LPAs inspected rooms in assisted living unit and rooms in the in the memory care unit. Sufficient furniture and lighting was observed throughout the facility and inside resident rooms. There are no bodies of water present in the facility. LPAs inspected the kitchen and dining room area and observed a sufficient supply of non-perishable and perishable food available on hand, while proper food preparation and storage was observed as well.

Smoke detectors are hard wired, and fire extinguishers are current and in compliance with the fire safety code. Facility has a built in sprinkler system and has yearly inspections and tests. LPAs observed that centrally stored medications, toxins, knives, and sharp objects are kept locked and inaccessible to clients.

No deficiencies were cited during this inspection. Exit interview held with Administrator, Nick Gaither, and a copy of this report was given at the conclusion of the visit.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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