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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 05/28/2021
Date Signed: 05/28/2021 01:09:44 PM

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:DAVIS GUEST HOME VIFACILITY NUMBER:
507003970
ADMINISTRATOR:HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:1209 CENTRAL AVENUETELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:9CENSUS: 9DATE:
05/28/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Lonny DavisTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 5/28/2021 at 12:40pm. LPA met with Lonny Davis and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 9 residents of which 0 are hospice.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. The temperature inside the facility was measured at 74 *F within the required range of 68*F and 85 *F. LPA observed residents finishing lunch matching daily menu including a variety of nutritious meals. LPA observed two staff providing care to meet residents needs and abilities. LPA observed centrally stored medications and cleaning supplies secure inaccessible to residents in care.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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