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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 10/12/2022
Date Signed: 10/14/2022 03:43:53 PM


Document Has Been Signed on 10/14/2022 03:43 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:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 2DATE:
10/12/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Cecilia CandidoTIME COMPLETED:
12:00 PM
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An informal conference was conducted today in the Sacramento Regional Office. The purpose of this informal conference meeting is to discuss the facilities continued Type A citing’s during Annual Inspections, and Plan of Correction visits. Present in the meeting is Licensing Program Manager Liza King, Licensing Program Analyst Sarah Hurt, Administrator Nikolas Admasson, and Licensee Cecilia Candido.

Issues discussed during the meeting were:
· Food service
· Medications accessible to residents
· Chemicals accessible to residents
· Facility is not clean and in good repair
· Swimming pool (empty) accessible to residents
· Knives accessible to residents
· Resident Personal Rights

The facility has stated they will do the following to achieve continued and substantial compliance:

· Lock all medications in a cabinet making them inaccessible to residents
· Lock the pool making it inaccessible to residents
· Keep chemicals in garage locked away
· Combustible chemicals to be kept locked away near empty pool
· Provide updated floor plan to include one storage room (store clutter)
· Ensure the facility, and all resident bedrooms are clean and not full of clutter.

Continued on 809C.. .
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
VISIT DATE: 10/12/2022
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Continued from 809..

Licensing will arrange a TSP (Technical Support Services) consultation to assist the facility in recognizing areas needed to improve. Licensing will increase monitoring to include a follow up to the visit on October 11, 2022 and quarterly visits to follow.

Licensee Cecilia Candido informed LPA Hurt, and LPM King she will likely not be present during Licensing’s November visit as she will be on vacation out of the country. Licensee Cecilia Candido authorized the LPA to conduct the visit with facility staff Marilou Oliver who is listed on the facilities LIC 308 (Designation of Facility Responsibility).


Exit interview conducted and a copy of this report provided to Licensee Cecilia Candido.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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