507003970-5-13-2022-27-AS-CYAG-CEDSCN-20220513134548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 05/04/2022
Date Signed: 05/13/2022 01:45:56 PM

Document Has Been Signed on 05/13/2022 01:45 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:	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:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Heather McClosky		TIME COMPLETED:	12:30 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 05/04/2022 by Licensing Program Analysts (LPA)s Charlie Yang and Arielle Pascua who were met by the facility caregiver, Tanya Sangster, and requested to go ahead and contact the facility designated Administrator, Heather McClosky, who arrived shortly thereafter. A brief interview was conducted with the facility designated Administrator. Current census was 9 residents. It was learned that there weren't any residents under the care of home health at this time. There weren't any residents under the care of hospice at this time. This facility does not carry a plan of operation to accept and retain residents diagnosed with dementia. This facility does not have a waiver to accept and retain any residents in need of hospice care. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time. A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in compliance at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Medication cabinet, located as a medication cart in the dining area, was reviewed. Policies and procedures for documenting, dispensing, and refilling the medications were discussed with the facility designated Administrator. Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities. Additional food storage units were observed to be present in the garage area.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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: 05/04/2022

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Garage area was toured. It was learned that this space was used to store furniture and items for resident use. Additional food supply quantities were observed to be present as well.
Fire extinguishers were observed to be placed throughout this facility and were annually inspected on 09/09/2021 by Gateway Fire Extinguisher Company and in compliance at this time.
First aid kit was observed to be present and contained all required components at this time.
Linen closet, located in facility restroom, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located next to the kitchen, was observed to be locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gate, and emergency exits were reviewed.

The following forms 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: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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