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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002067
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:45:53 PM

Document Has Been Signed on 11/28/2022 12:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SIERRA SALEM CHRISTIAN HOMES,INC.FACILITY NUMBER:
507002067
ADMINISTRATOR:BETHANY DUTTFACILITY TYPE:
735
ADDRESS:309 GAYLE AVENUETELEPHONE:
(209) 572-5050
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 4DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Deborah MensonidesTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection and met with care staff and later with Administrator Deborah Mensonides. LPA Lund explained the reason for the visit to Administrator Deborah Mensonides. Census 4

LPA Lund and Administor Deborah Mensonides. toured/inspected the interior and exterior of the facility. The facility is found to be clean, safe, sanitary, and in good repair. The facility temperature is at 72 degrees F. The hot water temperature is at 108 degrees F. There are no bodies of water present. Toxins and sharp tools are stored inaccessible to residents. LPA observed sufficient food supply. Fire extinguishers (service tag 1/4/2022), smoke detectors, and carbon monoxide detectors are in compliance. First aid kit is complete. Disaster drill conducted within last six months (8/22). LPA observed centrally stored medications are locked.

No deficiencies cited on today's visit. Exit interview conducted with Administrator Deborah Mensonides, and report left.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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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