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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002686
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:22:43 PM


Document Has Been Signed on 12/06/2023 01:22 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: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:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Staff member Imelda Bayani TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an Annual/Required inspection. LPA was met staff member Imelda Bayani and explained the reason for the visit. Administrator Genaro Baisac could not make the visit today.

LPA Lund and staff member Cheryl Rodriguez 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 observed 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. The facility has a swimming pool with locked. Smoke detectors and carbon monoxide detectors found in working order. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA Lund reviewed two staff & two residents files and were complete.

No deficiencies were cited at this time and copy of report given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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