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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004954
Report Date: 11/19/2021
Date Signed: 11/23/2021 11:02:03 AM

Document Has Been Signed on 11/23/2021 11:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DAVIS GUEST HOME VII/VILLAFACILITY NUMBER:
507004954
ADMINISTRATOR:SPEEGLE, MISTYFACILITY TYPE:
735
ADDRESS:1232 NADINE AVE.TELEPHONE:
(209) 554-5220
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 24CENSUS: 24DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Taylor TrammellTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 11/19/2021 by LPA Yang and was met by the facility designated Administrator, Taylor Trammell, who was briefly interviewed. This facility is not vendorized through Valley Mountain Regional Center at this time.
Current census was 24 residents.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. It was learned that all food supplies were ordered and delivered through a third party vendor. Additional freezer units were present and reviewed.
Resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Laundry area was reviewed and observed to contain a sufficient supply of blankets, bed coverings, and towels to meet the needs of the residents at this time.
Living room, dining room and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Medication cabinet, located in main office area, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in office area, was observed to contain all of the required components at this time.
Fire extinguishers were observed to have been annually inspected on 08/09/2020 by Gateway Fire Equipment and in compliance at this time.
Exterior grounds of this facility was conducted. Perimeter fence and gates were reviewed and found to be in functional order and in compliance at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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Document Has Been Signed on 11/23/2021 11:02 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/19/2021 at 12:09 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS GUEST HOME VII/VILLA
FACILITY NUMBER: 507004954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since flies were present throughout this facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2021
Plan of Correction
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Facility representative stated that a plan will be submitted into CCL detailing how the flies will be removed and prevented from this facility. A statement of correction will be completed with copies of receipts of any services rendered and submitted into CCL by the due date of 11/26/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DAVIS GUEST HOME VII/VILLA
FACILITY NUMBER: 507004954
VISIT DATE: 11/19/2021
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The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 rules and regulations, Health and Safety Codes.

Appeal rights were printed and given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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