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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001468
Report Date: 11/01/2021
Date Signed: 11/02/2021 10:55:05 AM

Document Has Been Signed on 11/02/2021 10:55 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:SIERRA SALEM CHRISTIAN HOMES INC.FACILITY NUMBER:
507001468
ADMINISTRATOR:DEBORAH MENSONIDESFACILITY TYPE:
735
ADDRESS:1805 WOODLAND AVENUETELEPHONE:
(209) 544-9300
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY: 6CENSUS: 6DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Deborah MensonidesTIME COMPLETED:
03:30 PM
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Unannounced annual visit made out to this facility on 11/01/2021 by LPA Charlie Yang to conduct an annual inspection. This LPA was met by the facility personnel who was requested, by this LPA, to contact the facility designated Administrator, Deborah Mensonides, to inform her that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this facility.
Current census was 6 residents.
This facility is licensed to accept and retain up to (6) residents at any given time. This facility is vendorized, through Valley Mountain Regional Center, to accept and retain Level 2 residents.
Tour of this facility was conducted.
Medication cart, located in staff restroom, was reviewed. Policies and procedures surrounding medications was discussed with the facility designated Administrator. First aid kit was observed to be present and contained all of the required components at this time.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient amount of flatware, dinnerware, and items for resident use.
Food storage units were reviewed to make sure that there was a sufficient supply of 2-day perishable and 7-day nonperishable quantities at all times. An additional food storage unit was observed to be in use and present in the garage area. Garage area was toured.
Laundry area was toured. It was learned that residents were encouraged and scheduled for completing their laundry with the assistance of facility personnel. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident rooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguisher, located in laundry area, was reviewed and observed to have been annually inspected on 12/17/2020 by the local fire extinguisher company.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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: SIERRA SALEM CHRISTIAN HOMES INC.
FACILITY NUMBER: 507001468
VISIT DATE: 11/01/2021
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Exterior grounds of this facility was toured. Perimeter fence and the main gate was observed to be maintained in good repair and 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 todays annual visit.

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

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC809 (FAS) - (06/04)
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