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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002686
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:41:58 PM


Document Has Been Signed on 01/06/2023 02:41 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:VALLEY ROYALE CAREFACILITY NUMBER:
507002686
ADMINISTRATOR:GENARO BAISACFACILITY TYPE:
740
ADDRESS:701 FLEETWOOD DRIVETELEPHONE:
(209) 577-3818
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 5DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Genaro Baisac TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund made an unannounced visit to the care home to conduct an Annual/Required inspection. LPA was met by Administrator Genaro Baisac and explained the reason for the visit.

LPA Lund and Administrator Genaro Baisac toured/Inspected the facility. There are three bedrooms and two bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector found in working order. Fire extinguishers and first aid kit are maintained and ready for emergency use.

LPA Lund spoke with Administrator Genaro Baisac regarding the COVID 19 for staff & visitors.

As a result of this visit, no deficiencies were cited at this time. Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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