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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001176
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:44:43 PM


Document Has Been Signed on 12/27/2023 02:44 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: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:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Nick Gaither TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct annual/required visit. LPA Lund met with Administrator, Nick Gaither and explained the purpose of the visit. Census:61

LPA Lund and Administrator Nick Gaither toured/inspected the 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. LPA Lund observed the common areas of the community to be free of odor and clean. LPA Lund 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. LPA Lund inspected the kitchen and dining room area and observed 7- day non-perishable and 2-day perishable food 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 Lund observed that centrally stored medications, toxins, knives, and sharp objects are kept locked and inaccessible to clients. LPA Lund reviewed four staff and four residents’ files and were in compliance.

No deficiencies cited during this visit. Exit interview held with Administrator, Nick Gaither, and a copy of this report given.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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