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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004675
Report Date: 06/26/2023
Date Signed: 06/26/2023 03:20:48 PM

Document Has Been Signed on 06/26/2023 03:20 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:
06/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Elizabeth Rodriguez YienTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with Administrator Elizabeth Rodriguez and explained the purpose of the visit.

LPA Lund & Administrator Elizabeth Rodriguez inspected/toured the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, activity room, and outside courtyards. LPA Lund observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven-day non-perishable and two- day perishable food supplies. Hot water temperature was measured at 108.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA Lund observed centrally stored medications are kept locked and inaccessible to residents. LPA Lund reviewed and compared resident medication vs. resident medication logs. LPA Lund reviewed 2 resident and 2 staff files, including criminal record clearances. First aid kit was checked and is complete. LPA Lund observed carbon monoxide detectors in the facility. Per the Title 22, Division 6 of California Code of Regulations. No deficiencies were observed during today's inspection.

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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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