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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004675
Report Date: 07/31/2026
Date Signed: 07/31/2026 05:10:28 PM

Document Has Been Signed on 07/31/2026 05:10 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:SUBLIME ADULT RESIDENTIAL, INC.FACILITY NUMBER:
507004675
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ YIEN, ELIZABETHFACILITY TYPE:
735
ADDRESS:1525 DEL MAR AVENUETELEPHONE:
(209) 549-9282
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 5CENSUS: DATE:
07/31/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Elizabeth YienTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility. LPA Met with Elizabeth Rodridguez Yien to explain the purpose of the visit. two bedrooms, two clients each and a staff room. there is one bathroom.

Physical Plant was inspected including the kitchen, bedrooms, bathrooms, exterior and evacuation route gate. Facility is clean, the traffic areas are unobstructed and well lit. the Kitchen, has storage space for toxics, sharps, and medication. there is food for 2 days perishable and 7 days non perishable foods. the bathroom has hardware in good repair, the water measured at the basin was between 105 and 120*F. the bedrooms, have required furniture and furnishings. the exterior is clean and space for activites, the evacuation route gate swings feely and latches closed. the extinguisher is dated 9/19/25, the CO and smoke allarms are functional, first aid kit has all necessary items.

LPA checked 2 mars and medications at random, in accordance with each other. the LPA reviewed documentation for refusals/PRNs/destruction. LPA checked 2 clients at random balance sheets, and monies, they are in agreement.

Staff files were reviewed including the health screanings, backround cheacks, recent and continuing trainings, and first aid/cpr. Files are present and up to date. Client files were reviewed including the admission agreements, health screenings, ipps, and most recent 602's. files are present and up to date

Administrator files were reviewed including the insurances, administrator certificate, facility license, required posters(ombudsman, personal rights, evacuation route, and menus) infection control plan, and evacuation plan. files are present and up to date. LPA asked for 2h of HIV/Bloodborne Pathogens training for the administrator to be emailed to the LPA, noel.wolfpetersen@dss.ca.gov. No Citations as part of this visit. a copy of the report was read and left with the administrator, exit interview conducted.
Liza King
Noel Wolf Petersen
DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2026
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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