<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001266
Report Date: 06/22/2023
Date Signed: 06/27/2023 11:29:02 AM

Document Has Been Signed on 06/27/2023 11:29 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 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: DATE:
06/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valeria OrozcoTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Unannounced case management visit made out to this facility on 06/22/2023 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility designated Administrator, Valeria Orozco, who was briefly interviewed.
Current census was 47 residents.
The purpose of this visit was to follow up on the incident report (LIC 624) that was submitted for R1 on 06/12/2023.
It was learned that R1 has been out of this facility since 06/12/2023 and has not returned to this facility. It was learned that as of today, 06/22/2023, the reserved space (bed) for R1 has been dropped by this facility after consulting with the County Conservator's Office.
It was learned that communication has been maintained with the County Conservator's Office since the initial date of R1 leaving this facility and has continued until now.
It was learned that there weren't any cameras or video recording for the exterior grounds of this facility. Residents were always instructed to sign in/out upon leaving/entering this facility.

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

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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 1