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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001266
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:23:12 PM

Document Has Been Signed on 04/03/2024 12:23 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DAVIS GUEST HOME #1FACILITY NUMBER:
507001266
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:
VALERIA OROZCOFACILITY TYPE:
735
ADDRESS:1878 E. HATCH RD.TELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 48CENSUS: 46DATE:
04/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Valeria Orozco, AdministratorTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
12:17 PM
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On 04/03/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a Case Management in regards to an AWOL incident. LPA Campbell spoke to Administrator Valeria Orozco regarding an AWOL that occurred on 03/06/2024. As reported from the facility incident report, Resident 1 (R1) had left the facility during bed checks and had not signed out. A search was done on the facility grounds and then in the nearby neighborhoods. Police were called. Staff found R1, 15 minutes away by car and supervisors were contacted. When asked, R1 agreed to return to David Guest Home #1 but when he arrived, R1 ran away to the nearby AM/PM. R1 began yelling when police arrived and had to be restrained and taken to Doctor Medical Center to be medically cleared. R1 was then taken Doctor Behavioral Health Center(DBHC).

R1’s Case Manager, Jorley Johnny stated that R1 needed a higher level of care once it was discovered R1 was no longer taking his medication at DBHC and therefore R1 could be discharged from Davis #1. Per the Administrator, R1 had been taking his medication while at the facility but they were not keeping up with their hygiene. Though R1 had only been present in the facility three or four days, they had not showered during that time. Staff were continuing to prompt R1 to bathe when R1 left the facility without notice. Per Administrator, as part of the pre-approval process, it was verified if R1 had been med compliant at other facilities and if he was bathing. When asked what actions could have been taken to avoid such outcomes in the future, Administrator Valeria Orozco stated that new residents may require a more in-depth review of their history as part of their pre-appraisal process.

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



Exit Interview
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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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