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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003970
Report Date: 09/17/2026
Date Signed: 09/17/2026 04:30:10 PM

Document Has Been Signed on 09/17/2026 04:30 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:
09/17/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:26 PM
MET WITH:HEather McCloskyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct a case management for the findings a recent report prepared by the department. The LPA met with administrator Heather McClosky to explain the purpose of the visit.

The findings of the Investigation Case Report are summarized:

December 22nd of 2025, client (R1) arrived to the hospital from a fall with head injury. Hospital records of that visit reviewed indicated that Resident 1 (R1) was severely malnourished. R1 lost more than 20% of their usual body weight from the time of July 6th of 2025 (169.9 lbs recorded by American Rescue Ambulance) to their hospitalization(due to a fall with head injury) on December 22nd of 2025 (119.9 lbs recorded by American Rescue Ambulance). Staff 2(S2) in interview described R1's fall on December 22nd as a result of attempting to quickly reach the restroom, as R1's loose, unbelted falling down pants, presented a tripping hazard which resulted in the injury.

In interview, Administrator McClosky reported completing an appraisal of R1 upon admission and gave a statement that she did not belive R1's condition had changed since their admission and therefore did not complete or document a reassessment. Further, she did not believe anything could have been done differently in R1's case and there was no lack of care and supervision that contributed to R1's decline in health.

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Liza King
Noel Wolf Petersen
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/17/2026
NARRATIVE
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Record review of r1's 602 dated April 2025 lists physical health status as fair, no special diet, and is able to feed himself, and prescriptions included mood stabilizers, appetite stimulants, and oxygen. R1's weight was recorded as 136lbs at admission(may 2025). R1 is described by Staff 3(s3) as "good when [they] arrived at the facility, [they were] independent and able to perform ADLs on their own". R1 is described by Staff 2(s2) as "very active and left his room often to socialize with others".

Record review of the primary care physician's notes described r1 as "thin, frail, and fragile" in June 2025. record review of a caseworker's vists for R1 noted [R1 was] "much thinner than their last visit" in June 2025 and "visibly thinner and clothes no longer fit" in October 2025. It was learned in record review, R1's meal refusing related behaviors were documented by the facility going back to October of 2025. Staff 2(s2) gave a statement that R1's behavioral decline (not wanting to get out of bed, increased irritability) was communicated to R1's responsible party in October via telephone. S4 recalls meeting R1 for the first time in November and gave the statement "[R1] was thin, frail, and appeared malnourished,". Record review of medical records from a hospital visit from November 2025 indicated R1 presented with a productive cough and congestions with recent onset, and lab results that showed a pattern that may be consistent with decreased blood flow to the kidneys, linked to dehydration or heart failure. S4 reported R1 refused to engage with their ADLs in December, and began refusing medications towards the end of their stay at DGH.

Collectively, these records and interviews indicate r1 was deteriorating physically and mentally for several months significantly from the starting point of being independent and able to take care of ADLs, most notably the increase in r1's behaviors of agitation and isolation and refusals to bathe and eat.

while S3 reportedly took action to inform the reporting party as early as October regarding behaviors, no documentation supports the claim the reporting party was informed by the facility of R1's weight loss( as required in CCR section 87466 Observation of the Resident). While Administrator McClosky gave a statement that she verbally told the conservator in October that r1 was ready to move on to a new facility, no reappraisal or supporting documentation was made at that time and the administrator gave a statement that she did not believe a change in condition had occurred. Around December 8th of 2025, DGH submitted to r1's conservator a referral for seeking a higher level of care for r1.

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NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
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: 09/17/2026
NARRATIVE
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A concensus statement was not reached about a claim asserting the facility did not monitor the residents for signs of lithium toxicity. S2 staff gave a statement they noticed a decline in r1's weight in December coinciding with r1 becoming sick and lethargic. S3 gave a statement they did not observe signs and indicated r1 was more typically agitated than lethargic. Record review of r1's Lab work from the hospital visit of December 22nd indicated r1 was 1.1 on an acceptable range of .6 to 1.2. Unclear if lithium was one of the medications r1 refused towards the end of December.

The report concludes, As to the neglect/lack of supervision in the aspect that r1 sustained significant weight loss due to staff neglect, an substantiated finding. The interviews of staff, the administrator, the caseworker, and conservator collectively describe R1 going from social to asocial, fair to malnourished from summer 2025 to winter of 2025. facility didn't meet its documentation(reappraisals triggered by presenting a danger to others, deterioration of mental ability, and unusual weight loss, deterioration of a physical health condition or changes in ability to care for or maintain ADLS independently) or reporting requirements regarding r1's care(physician, responsible party, and CCL should be informed of unexplained absences from the facility e.g. hospitalizations). If staff had met those requirements, they may have had the evidence to support moving the client to a higher level of care in when the administrator expressed interest in October, ahead of the more severe decline in December.

An exit interview was conducted where this report was reviewed with the Administrator, citations were reviewed and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 04:30 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 09/17/2026 at 03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS GUEST HOME VI
FACILITY NUMBER: 507003970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2026
Section Cited
CCR
87463(a)

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87463(a) Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement was not met as evidenced by:
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The LPA recommended as aplan of correction : administrator should make a policy for how/when the reappraisal needs to be updated for a resident, send the policy to the LPA eod 9/25/26
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r1 has a significant change in condition(refusing food, refusing bathing, refusing to leave his room, hitting his doc), new diagnosis 10/2025,
Per administrator interview, there were no documented attempts by the facility to reappraise the client’s needs for this period. In other interviews, staff (s2, s3, s4), and caregiver(cg1) gave statements that collectively corroborate a physical/behavioral decline in ADL performance for r1: agitation expressed by throwing food/ refusing to come out of their room /refusing meals/ low oral intake for nonpreferred meals/clothing no longer fitting; for the period of July 2025 to December 2025

Not following this requirement poses a risk to the residents health, safety, and personal rights
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Type B
09/24/2026
Section Cited
CCR87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

Not following this requirement was evidenced by:
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The LPA recommended as a plan of correction : administrator should send back a signed copy of 87211 signifying understanding of the regulation to the lpa(9/25/26).
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record review of a client's 8 emt evaluations leading to 6 hospital visits, only 2 of 6 made it to being reported to licensing as required.

Not following this requirement posed a potential risk to the health, safety, or personal rights of clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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