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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001184
Report Date: 03/07/2022
Date Signed: 03/22/2022 02:39:40 PM


Document Has Been Signed on 03/22/2022 02:39 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:DAVIS GUEST HOME #5FACILITY NUMBER:
507001184
ADMINISTRATOR:HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:2405 MAUNA LOA DRIVETELEPHONE:
(209) 556-9204
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY:8CENSUS: 6DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria Bravo, Brittany Miller, and Heather McCloskyTIME COMPLETED:
01:30 PM
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Unannounced annual visit made out to this facility on 03/07/2022 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility caregiver, Brittany Miller, and house manger, Maria Bravo, who were requested by this LPA to go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. The facility designated Administrator, Heather McClosky, arrived shortly thereafter to this facility. Brief interview conducted with the facility designated Administrator.
This facility accepts and retains up to 8 residents at any given time, of which only (2) can be non ambulatory, while the other (6) are ambulatory only.
Current census was 6 residents.
Tour of this facility was conducted.
Kitchen area was toured. Food storage units were reviewed for 2-day perishable and 7-day nonperishable food quantities. Additional food supplies were observed to be present in the garage storage unit. Freezer unit and additional nonperishable food quantities were present and observed at this time.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 09/09/2021 by the local fire extinguisher company and in compliance at this time.
Laundry area, located adjacent to family room, was toured.
Medication cart, located in the dining area, was reviewed. It was observed to be locked and made inaccessible to the residents at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured.
The facility perimeter fence, side gates, and exits were reviewed at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DAVIS GUEST HOME #5
FACILITY NUMBER: 507001184
VISIT DATE: 03/07/2022
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Linen closet was reviewed and observed to contain a sufficient supply of towels, sheets, and linens to be able to meet the needs of the residents at this time.

The following forms and documents were requested to be updated and submitted into CCL:
  1. LIC 308
  3. LIC 400
  5. LIC 500
  7. LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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