507003970-6-22-2021-27-AS-CYAG-C48PL2-20210622112400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 05/25/2021
Date Signed: 06/22/2021 11:24:03 AM

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 VI		FACILITY NUMBER:	507003970
ADMINISTRATOR:	HEATHER MCCLOSKY		FACILITY TYPE:	740
ADDRESS:	1209 CENTRAL AVENUE		TELEPHONE:	(209) 538-1496
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	9	CENSUS: 9	DATE:	05/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Heather McClosky		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 05/25/2021 by LPA Yang and was met by the facility house manager, Tanya Sangster, and facility caregiver Esmeralda Teixiera, who were briefly interviewed. This LPA requested that the house manager go ahead and contact the facility designated Administrator to let them know that CCL was present at this time. Facility designated Administrator, Heather McClosky, arrived shortly thereafter to this facility while LPA was conducting this visit. Current census was 9 residents. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. Garage area was utilized as main food storage unit with two additional refrigerator units as well. It was learned that all food supplies are ordered and delivered through a third party vendor. Resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Resident restrooms were toured. Grab bars and non skid mats were observed to be present and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet was reviewed and observed to contain a sufficient supply of blankets, bed coverings, and towels to meet the needs of the residents at this time. Living room, dining room and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Medication cabinet, located in main dining area, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in kitchen area, was observed to contain all of the required components at this time. Fire extinguishers (6) were observed to have been annually inspected on 09/12/2020 by Gateway Fire Equipment and in compliance at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 VI	FACILITY NUMBER: 507003970
	VISIT DATE: 05/25/2021

NARRATIVE

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Exterior grounds of this facility were reviewed. It was observed that there was an additional living unit in the backyard of this facility which served as the housing unit for the maintenance worker. This unit has not been used in over a year and there were not any residents occupying this space at this time.
Perimeter fence, side gates, and all exits were reviewed.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC809 (FAS) - (06/04)

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