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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507004929
Report Date:
05/10/2024
Date Signed:
05/10/2024 03:33:34 PM
Document Has Been Signed on
05/10/2024 03:33 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 I
FACILITY NUMBER:
507004929
ADMINISTRATOR:
CANDIDO, CECILIA
FACILITY TYPE:
740
ADDRESS:
4112 LAURANT COURT
TELEPHONE:
(209) 521-0566
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
6
CENSUS:
2
DATE:
05/10/2024
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
02:35 PM
MET WITH:
Cecelia Candido
TIME COMPLETED:
03:45 PM
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On 5/10/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee Cecelia Candido and explained the purpose of today's visit.
There are currently 2 clients in care. LPA Jensen checked the water temperature in the hallway bathroom and it was 118 degrees Fahrenheit which is in compliance. LPA Jensen observed the fire extinguisher to have been purchased new on 10/17/23 which is in compliance. The Emergency disaster plan was last updated on 4/18/24 to reflect a change in facility vehicles. LPA obtained a copy of the updated Emergency disaster plan for the master file. LPA Jensen toured the backyard and observed the pool to be locked and inaccessible to residents in care. LPA Jensen interviewed co-administrator Nikolas Adamsson who explained that the facility is in the process of digitizing all facility records. LPA Jensen observed the medication cabinet to be locked and inaccessible to residents in care. LPA Jensen provided technical assistance on waiver programs and HCBS.
No deficiencies were issued as a result of this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Maja Jensen
TELEPHONE:
(916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
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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