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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001176
Report Date: 01/06/2023
Date Signed: 01/06/2023 12:21:33 PM


Document Has Been Signed on 01/06/2023 12:21 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
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: 69DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Chris Gaither TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual required visit. LPA met with Administrator Chris Gaither and the explained the reason for the visit.

LPA Lund & Administrator Chris Gaither toured/Inspected the facility with including the 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. LPA observed the common areas of the community to be free of odor and clean. LPA inspected rooms in assisted living unit and rooms in the in the memory care unit. Sufficient furniture and lighting were observed throughout the facility and inside resident rooms. LPA 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. LPA 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, Chris 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: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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