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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002067
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:43:05 PM

Document Has Been Signed on 11/27/2023 02:43 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: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:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Dorothy Lopez TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met Administrator Dorothy Lopez and explained the reason for the visit. Census 4

LPA Lund and Administrator Dorothy Lopez 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 75 degrees F. The hot water temperature is at 109 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 1/4/2023), smoke detectors, and carbon monoxide detectors are in compliance. First aid kit is complete. Disaster drill conducted within last six months (11/23). LPA observed centrally stored medications are locked. LPA reviewed two staff & two clients files.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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