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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 02/02/2024
Date Signed: 02/02/2024 05:45:52 PM


Document Has Been Signed on 02/02/2024 05:45 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 8DATE:
02/02/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Heather McCloskyTIME COMPLETED:
02:00 PM
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Unannounced Plan of Correction visit was made out to this facility on 02/02/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Heather McClosky.
A brief interview was conducted with the facility designated Administrator at this time.
Current census was 8 residents.
The purpose of this plan of correction visit was to follow up on deficiencies that were observed and cited on a prior visit, conducted on 12/15/2023, for the following:

Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in
(2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
This facility did not meet the requirements as evidenced by not submitting the required information on forms and documents by the required timeframes.

The plan of correction was completed by this facility by the due date. The Proof of Correction letter was printed and a copy was given to the facility designated Administrator.

There were no additional deficiencies observed or cited during today's plan of correction visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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