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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 09/25/2025
Date Signed: 09/25/2025 01:38:37 PM

Document Has Been Signed on 09/25/2025 01:38 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:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR/
DIRECTOR:		CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 4CENSUS: DATE:
09/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Cecilia Candido, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 9/25/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required 1-year annual inspection. LPA was greeted by Administrator Cecilia Candido. LPA Lindstrom introduced herself and explained the purpose of the visit. The co-Administrator Nikolas Adamsson was also present. Both Administrators have valid Administrator’s certificates.

The facility has four bedrooms and two bathrooms. The current census is two residents. Two bedrooms were in use by residents, and the third and fourth bedrooms have been designated as office and storage.

The LPA toured the interior of the facility. The interior is decorated and contained adequate furniture for residents in the living room, entertainment room, and dining room. The bedrooms were clean and contained the required furniture. The bathrooms were clean. The water temperature in the hallway bathroom was 119 degrees Fahrenheit. The smoke and carbon monoxide detectors were wired together and in working order. The fire extinguisher was purchased on 11/8/2024 and had been checked monthly by staff. The administrator reviewed the emergency disaster plan last month and there were logs of quarterly disaster drills.

The LPA inspected the kitchen. The LPA observed that several opened food items that require refrigeration after opening were in the kitchen cabinets, unrefrigerated. There were several perishable and nonperishable food items in the refrigerator and pantry that were expired. There were cleaners and chemicals stored in kitchen cabinets with food. There was a two-day supply of perishable food and seven-day supply of non-perishable food in the kitchen and garage. The LPA inspected the medication storage and records. Medication was stored in a locked cabinet in the kitchen. The paper-based medication administration record produced by the pharmacy was complete and up to date.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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Document Has Been Signed on 09/25/2025 01:38 PM - It Cannot Be Edited


Created By: Ellen Lindstrom On 09/25/2025 at 12:47 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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of food in the kitchen, the licensee did not comply with the section cited above, as there were food items that were expired in the refrigerator and pantry, and there were open food items that required refrigeration after opening that were stored in the pantry unrefrigerated, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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The Administrator began conducting an inventory of the food supply and discarding expired and unrefrigerated food. The Licensee agrees to conduct a monthly audit of the food supply to identify and discard all and unrefrigerated expired food. The Administrator will send LPA an email when inventory and discard is complete.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of items in kitchen cabinets, the licensee did not comply with the section cited above, as ant and roach killer and leather cleaner were observed stored with food items in the cabinets, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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The Administrator will remove cleaners and pesticides from food storage areas and put them in a locked cabinet separate food. The Administrator will email LPA when this is complete.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
VISIT DATE: 09/25/2025
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The LPA inspected the grounds. The front yard was manicured and contained decorative plantings. The backyard contained a large pool that was behind a locked gate. The walkways were free of obstruction. There was no shaded outdoor activity area for residents.

The LPA inspected two staff and two client files, which were compete.

As a result of this inspection, deficiencies were cited. The facility was not in compliance with California Code of Regulations (CCR), Title 22, Division 6. The deficiencies are listed on the attached LIC 809D. Failure to correct deficiencies by the noted due date may result in the assessment of civil penalties.

An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report, the LIC 809D, and the appeals rights was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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