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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001266
Report Date: 04/06/2023
Date Signed: 05/02/2023 04:05:43 PM

Document Has Been Signed on 05/02/2023 04:05 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 #1FACILITY NUMBER:
507001266
ADMINISTRATOR:VALERIA OROZCOFACILITY TYPE:
735
ADDRESS:1878 E. HATCH RD.TELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 48CENSUS: 48DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valeria OrozcoTIME COMPLETED:
01:00 PM
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Unannounced annual visit conducted on 04/06/2023 by Licensing Program Analyst, (LPA) Charlie Yang, who was met by the facility designated Administrator, Valeria Orozco, who was briefly interviewed at this time. Census at this time was 48 residents. It was learned that there weren't any residents under the care of home health or hospice at this time.
Tour of this facility was conducted alongside the facility designated Administrator Valeria Orozco.
Fire extinguishers were last inspected on 08/12/2022 by the local fire extinguisher company, Gateway Fire Equipment, and observed to be in compliance at this time.
The designated Administrator Certificate for Valeria Orozco, #6064194735 was recently updated and will expire on 09/21/2024.
LPA observed that all resident medications and logs were stored in the medication area adjacent to the dining area. This area was closed off and made inaccessible to the residents at this time. Policies and procedures were discussed with the medication technicians who were present in regards to handling, dispensing, and documentation of the resident medications.
A sample of resident bedrooms was reviewed and all were found to contain furnishings and lighting to be in compliance at this time.
Resident restrooms were toured. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times.
It was observed that the laundry room was kept locked and made inaccessible to the residents at this time.
The kitchen area was toured and LPA found that all sharps were secured in a locked drawer. Residents do not have access to the kitchen and it was kept locked when staff were not present.
It was observed at this time that the majority of food supplies were stored in a separate building with a pantry, commercial refrigerators and freezers.
There was an adequate supply of 7 day non-perishable and 2 day perishables at this time.
It was observed that the majority of the heavy linens, blankets, and resident belongings were washed in this area of the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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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 #1
FACILITY NUMBER: 507001266
VISIT DATE: 04/06/2023
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A tour of the facility exterior grounds was conducted.
A review of the facility perimeter fence, side gates, and exits was conducted.

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

LIC 308

LIC 400

LIC 500

LIC 610


There were no deficiencies observed or cited during this annual visit at this time.

Exit interview.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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