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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001184
Report Date: 02/23/2023
Date Signed: 02/28/2023 01:06:24 PM


Document Has Been Signed on 02/28/2023 01:06 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 AC/SC, 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: 8DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Heather McCloskeyTIME COMPLETED:
12:30 PM
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Unannounced annual visit was conducted by Licensing Program Analysts (LPAs), Kimberly Viarella and Charlie Yang, on February 23, 2023. LPAs were met by staff member, Maria Bravo. Ms. Bravo was instructed to notify the designated facility administrator, Heather McCloskey, that Community Care Licensing was on the premises to conduct the annual review. The facility designated Administrator Heather McCloskey arrived shortly after. Brief interview was conducted with the facility staff and facility designated Administrator.
The facility designated Administrator, Heather McCloskey, was observed to have the RCFE Certificate, # 6008133740, which was set to expire on 09/28/2023.
Census at this time was 8 residents. There have been no new physical plant changes since the last annual conducted.
Fire extinguishers were last inspected by Gateway on August 15, 2022. Bathrooms were sanitary and no toxic chemicals were present.
The water temperature was measured in the hallway bathroom and was within the allowed range of 105 and 120 degrees.
Resident bedrooms were observed to have sufficient furniture and lighting. LPAs interacted with residents who appeared to be content and going about their daily activities.
The medication cart and logs were reviewed, including the medication disposal log. At this time all appeared to be in organized and in order.
The First Aid kit was inspected and contained all of the required components at this time.
All sharps and toxic chemicals in the kitchen were kept in locked cabinets and under the sink respectively. Additional dry goods and a second freezer was located in a locked storage.
The food supply was inspected and there was a sufficient 2 day perishables, as well as a sufficient 7 day non-perishables food supply.
The exterior grounds were inspected and found to be in good order and free of debris and tripping hazards. There were no bodies of water. There was a shed with a lock that contained holiday decorations, extra furniture and other items for storage.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DAVIS GUEST HOME #5
FACILITY NUMBER: 507001184
VISIT DATE: 02/23/2023
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There were no deficiencies observed or cited at this time.

The following documents were requested to be updated and submitted into CCL for review by the LPA:

LIC 308

LIC 400

LIC 500

LIC 610

A copy of the updated Liability Insurance


Exit interview.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2