507001266-4-21-2026-27-AS-NWPN-DTCSNC-20260421140121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507001266
Report Date: 04/21/2026
Date Signed: 04/21/2026 02:01:29 PM

Document Has Been Signed on 04/21/2026 02:01 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 #1		FACILITY NUMBER:	507001266
ADMINISTRATOR/ DIRECTOR:	MISTY SPEEGLE		FACILITY TYPE:	735
ADDRESS:	1878 E. HATCH RD.		TELEPHONE:	(209) 538-1496
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY: 48		CENSUS: 48	DATE:	04/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Josiah Nickols		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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	On 04/21/2025, Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unannounced to conduct an annual inspection. LPA met with administrator Josiah nickols and later administrator of record Misty Speegel and explained the purpose of the visit. a 200 has been submited changing Josiah to the administrator of record, LPA will follow up to complete the transition. The facility is a one story building that is licensed to serve 48 clients between the ages of 18 and 59. Of the clients residing in the facility, only 8 of them may be non-ambulatory. Referrals to the facility come from nearby counties public gaurdian office/behavioral heatth. Fire extinguishers are dated 8/4/25, water temperature is within the required 105-120*F. Physical inspection was completed including but not limited to: the kitchen, bedrooms, common areas, exteriors, and evacuation route. facility is clean and traffic areas are unobstructed and well lit. Kitchen has adequate lockable storage for sharps and toxics, medications are stored locked independent of the med pass where they have lockable carts. Kitchen has adequate supply for 7 days nonperishable, 2 days perishable, x96 residents x3 meals a day plus snacks between each meal. Bedrooms have adequate furniture and furnishings including mattress encasements. Common areas and exteriors have adequate space for activities. LPA asked the designated evacuation route gates on the facility sketch remain unlocked. Continued on c, page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS GUEST HOME #1	FACILITY NUMBER: 507001266
	VISIT DATE: 04/21/2026

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LPA reviewed administrator documents, including liability/workers comp insurance, surety bond, control of the property(via grant deed emailed to the lpa noel.wolfpetersen@dss.ca.gov), infection control plan, evacuation control plan, and plan of op. documents are present and up to date. LPA gave guidance that if any of the policies should change as a result of our conversation those updates should make it to the plan of operation, and then sent to the department for review.

LPA reviewed 5 client files, health screenings, recent medical assessments, needs and services plans, and signed admission agreements. Documents are present and up to date.

LPA reviewed 5 staff files, health screenings, continuing and initial trainings, first aid cpr and backround clearance are present and up to date. .

LPA interviewed 2 staff and 2 clients.

no citations as part of this visit, a copy of the report was read and given to the administrator. exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

LIC809 (FAS) - (06/04)

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