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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001184
Report Date: 01/25/2024
Date Signed: 01/25/2024 11:48:17 AM


Document Has Been Signed on 01/25/2024 11:48 AM - 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: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:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Heather McClosky, AdministratorTIME COMPLETED:
12:00 PM
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On 01/25/24, Licensing Program Analyst Renee Campbell made an unannounced visit to the facility at approximately 0900. LPA Campbell met with Heather McClosky, Administrator and stated the purpose of the visit.

LPA Campbell toured the facility with the administrator including the living room, bedrooms, bathrooms, outdoor storage and pantry. The facility currently has 8 ambulatory residents. LPA Campbell observed grounds were maintained and paths were clear of debris. Windows and screens were intact. The facility was observed to be sanitary and free of odor. The fire extinguisher was last checked on 01/23/24. Both the carbon monoxide and smoke alarm were tested successfully during today’s visit. The first aid kit was observed with bandages, tweezers and a thermometer. Client medication was observed to be locked in the medcart in the containers they came in and organized by client. The bathroom contained grab bars and the hot water from the faucet was measured at 109 degrees Fahrenheit. The thermostat was measured at 72 degrees Fahrenheit.

The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was fresh fruit and vegetables available for residents in care. All knives, toxins and chemicals were observed to be locked and inaccessible to residents in care. LIC 610E, Emergency and Disaster Plan is posted and current. Of the 8 residents, 2 client files were reviewed. Of the 10 staff, 2 staff files were reviewed.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview was conducted with Administrator and a copy of this report was left at facility..

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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