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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 06/22/2023
Date Signed: 07/10/2023 11:43:01 AM


Document Has Been Signed on 07/10/2023 11:43 AM - 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 AC/SC, 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: 3DATE:
06/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Cecilia CandidoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit regarding the Non-compliance conference (NCC) meeting. LPA was greeted by licensee and explained the reason for the visit.

During the NCC meeting the licensee agreed to:
· conduct Personal Rights Training every 6 months and upon new last date of training was are not up to date
· Clean and organize the client room that is being used as a storage room prior to the next quarterly visit. As of todays date this has been started but not completed.
· The Facility re-purposed 4 pantry drawers for medication and has secured them with locking mechanisms. As of todays date all medications were secured.
· The pool and chemicals are now secured and inaccessible to residents.
· Administrator has started to de-cluttered and cleaned the facility but has not completed it.

Person rights training was conducted on todays date 6/22/23, the next training is due by October 12th 2023. the licensee states that someone will be coming on Saturday 6/24/2023 to clear the clutter on the outside of the facility. There has been great improvement in the condition of the facility. The client room being used for storage has been cleaned and shows great improvement, the pantry drawers for medication continue to be locked, although the facility is improving there is still a lot of clutter that needs to be cleared out. Pool chemicals are secured and locked to residents in care.

Exit interview conducted and report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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