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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004675
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:36:01 PM

Document Has Been Signed on 06/16/2022 02:36 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:SUBLIME ADULT RESIDENTIAL, INC.FACILITY NUMBER:
507004675
ADMINISTRATOR:RODRIGUEZ YIEN, ELIZABETHFACILITY TYPE:
735
ADDRESS:1525 DEL MAR AVENUETELEPHONE:
(209) 549-9282
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 5CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Elizabeth Rodriguez Yien TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above facility unannounced to conduct a Required/Annual Inspection. LPA met with Elizabeth Rodriguez Yien, Licensee and explained the reason for the visit. This facility is approved to serve 5 ambulatory residents.

LPA & Administrator toured and inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction.

LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed 2-day perishables and 7-day non-perishables during this visit.

LPA observed the fire extinguisher(s), carbon monoxide and smoke detectors were present during this visit. Facility also has central heating and air.

No deficiencies cited
Exit interview held. A copy of todays’ report provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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