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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002067
Report Date: 12/11/2024
Date Signed: 12/11/2024 06:28:56 PM

Document Has Been Signed on 12/11/2024 06:28 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/
DIRECTOR:
BETHANY DUTTFACILITY TYPE:
735
ADDRESS:309 GAYLE AVENUETELEPHONE:
(209) 572-5050
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Dorothy Lopez TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jason Lund conducted an unannounced annual/required inspection and met Administrator Dorothy Lopez with and explained the reason for the visit.

LPA Lund & Administrator Dorothy Lopez toured/inspected the interior and exterior of the facility. LPA interacted with residents. The facility is found to be clean, safe, sanitary, and in good repair. The facility temperature is at 76 degrees F. The hot water temperature measured in a resident accessible bathroom sinks at 110 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 December 2023), smoke detectors, and carbon monoxide detectors are in compliance. First aid kit is complete. Emergency drill last conducted on (11/16/24).

LPA reviewed a sampling of (2) resident and (2) staff files (reviewed staff has criminal record clearance). LPA observed centrally stored medications are locked. LPA compared (2) residents’ medications with medication records.

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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