507003970-5-30-2023-27-AS-CYAG-CSC2ED-20230530171947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 05/19/2023
Date Signed: 05/30/2023 05:19:51 PM

Document Has Been Signed on 05/30/2023 05:19 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 AC/SC, 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:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Heather McClosky		TIME COMPLETED:	01:00 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 05/19/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Heather McClosky, who was briefly interviewed at this time. 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 since this facility did not carry an approved hospice waiver. This facility does not carry a plan of operation to accept and retain residents diagnosed with dementia either. 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 dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time. 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. 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS GUEST HOME VI	FACILITY NUMBER: 507003970
	VISIT DATE: 05/19/2023

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Fire extinguishers were observed to be placed throughout this facility and were annually inspected on 08/15/2022 by the local fire equipment company, Gateway Fire Extinguisher Company, and in compliance at this time.
First aid kit was observed to be present and contained all of the 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.
Additional shed in the backyard was reviewed and observed to be locked and made inaccessible to the residents at this time.
Additional housing unit was observed to be locked and used solely for storage by the Licensee.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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