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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 04/18/2024
Date Signed: 05/06/2024 03:52:40 PM

Document Has Been Signed on 05/06/2024 03:52 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:DAVIS GUEST HOME VIFACILITY NUMBER:
507003970
ADMINISTRATOR/
DIRECTOR:		HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:1209 CENTRAL AVENUETELEPHONE:
(209) 538-1496
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 9CENSUS: 9DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Heather McCloskey, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to this facility to conduct an annual inspection on 04/18/2023 at 9:30 AM.  LPA Campbell met with  Heather McClosky, Administrator and stated the purpose of today’s visit. LPA Campbell inspected the physical plant to ensure compliance with Title 22 regulations.

The facility is a one floor building licensed to service adults age 60 and over. The facility may serve up to 9 residents. Two may be nonambulatory residents in room 4 only. The Plan of Operation does not allow for care of residents with dementia. No hospice waiver may be granted. No body of water was found. Upon entry, LPA Campbell observed a resident sitting on the couch in front of the TV and several residents were socializing with staff in the dining room.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyard of the facility. The courtyard had several seating areas under shade. A combination wood and black iron gate surrounded the backyard and provided security for the residents with a fire exit that lead to the front yard. Several residents also have patio door access to the outside as well.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DAVIS GUEST HOME VI
FACILITY NUMBER: 507003970
VISIT DATE: 04/18/2024
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The facility was observed to be free of odor and in good repair. LPA Campbell observed that two residents lived in a room with an en suite private  bathroom.   There was a hallway bathroom for the rest of the residents, and guests.  There were no changes to the building layout since the most recent floor plan.  A fire extinguisher was observed to have last been inspected on 08/08/2023. The thermostat was set at 73 degrees Fahrenheit.

LPA Campbell observed a washer and dryer along with the staff bathroom in a secured room between the garage and the kitchen. There were enough perishable foods to sustain the facilty for 3 days and enough non-perishable foods to last 7 days. The temperatures for the freezer and the refrigerator were in compliance. The administrator conducted a test for the smoke alarm and the carbon monoxide alarm successfully.
There were no deficiencies observed during visit. Exit interview and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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