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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001468
Report Date: 12/12/2022
Date Signed: 12/30/2022 10:47:47 AM

Document Has Been Signed on 12/30/2022 10:47 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:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma QuezadaTIME COMPLETED:
12:00 PM
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Unannounced annual visit made out to this facility on 12/12/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person. This LPA requested that they go ahead and notify the facility designated Administrator, Deborah Mensonides, to inform her that CCL was present at this time to conduct the annual visit. Brief interview was conducted with the facility staff person at this time.
It was learned that this facility is also vendorized through Valley Mountain Regional Center (VMRC) to be able to accept and retain (6) Level 2 residents at any given time.
Current census was (6) residents, of which (4), were out of this facility at their respectable day programs at this time with (1) at a doctors appointment and (1) resident was present at this time.
Tour of this facility was conducted alongside the facility staff person.
Dining area, living areas, and all other areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility kitchen was conducted.
Food storage was reviewed to make sure that this facility maintained the appropriate 2-day perishable and 7-day nonperishable quantities at all times.
Medication cart, located in the restroom, was observed to be locked and made inaccessible to the residents at this time. Policies and procedures were discussed with the facility staff person in regards to handling, dispensing, and proper documentation of the resident medications.
First aid kit, located in the medication cart, was observed to be present and contained all of the required components at this time.
Fire extinguisher, located hanging in the laundry area, was observed to have been annually inspected on 01/04/2022 by the local fire extinguisher company, Jorgensen and Company, and in compliance at this time.
A tour of the facility resident bedrooms was conducted. 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 facility resident restrooms was conducted. Hot water temperatures were taken and measured to
make sure that they were within the allowed range of 105-120 degrees.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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: 12/12/2022
NARRATIVE
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SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
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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: 12/12/2022
NARRATIVE
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Laundry room and area intended for washing, folding, and preparation of the clothes and linens for the residents was toured. Cleaning supplies and laundry supplies were observed to be locked and made inaccessible to the residents at this time.
Linens were observed to be present and sufficient to meet the needs of the residents at this time.
Garage area was toured. Additional food storage units and nonperishable food products were observed to be present at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, 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

The following deficiencies were observed and cited during today's annual visit on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility staff person at this time.

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

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/30/2022 10:47 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/12/2022 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SIERRA SALEM CHRISTIAN HOMES INC.
FACILITY NUMBER: 507001468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


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