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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001266
Report Date: 04/04/2022
Date Signed: 04/05/2022 08:54:39 AM

Document Has Been Signed on 04/05/2022 08:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DAVIS GUEST HOME #1FACILITY NUMBER:
507001266
ADMINISTRATOR:LONNY DAVISFACILITY TYPE:
735
ADDRESS:1878 E. HATCH RD.TELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 48CENSUS: 47DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Heather McCloskyTIME COMPLETED:
01:00 PM
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Unannounced annual visit conducted on 04/04/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Heather McClosky who was briefly interviewed.
Current census was 47 residents.
Tour of the facility was conducted.
Medication area and medication carts were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 09/08/2021 by the local fire extinguisher company, Gateway Fire, and in compliance at this time.
Tour of the facility resident bedrooms was conducted. It was learned that there were two separate wings for the residents at this time. One wing was solely for the male residents and the other wing was solely for the female residents. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured and hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Shower units and bathing units were toured. These units were separate from the facility resident restrooms.
Facility food storage area was toured. A review was conducted to make sure that this facility had a sufficient supply of 2-day perishable and 7-day nonperishable food quantities at all times.
Laundry area was toured. It was observed that this area was locked and made inaccessible to the residents at this time. It was learned that resident clothes and bedding were washed in this laundry area while the heavier items such as comforters and blankets were washed in the larger commercial washer as needed.
A tour of the kitchen area was conducted. It was learned that meals were prepared and served to the residents by facility staff.
Dining area, living room areas, 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.
Linen supplies were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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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 #1
FACILITY NUMBER: 507001266
VISIT DATE: 04/04/2022
NARRATIVE
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First aid kit was observed to be present and contained all of the required components at this time.
A tour of the facility exterior grounds was conducted.
Facility perimeter fence, side gates, and exits were reviewed and observed to be in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

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

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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