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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004954
Report Date: 11/30/2022
Date Signed: 12/01/2022 11:59:55 AM

Document Has Been Signed on 12/01/2022 11:59 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:JESSICA SANCHEZFACILITY TYPE:
735
ADDRESS:1232 NADINE AVE.TELEPHONE:
(209) 554-5220
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 24CENSUS: 24DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica SanchezTIME COMPLETED:
12:30 PM
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Unannounced annual visit made out to this facility on 11/30/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jessica Sanchez who was briefly interviewed.
Current census was 24 residents.
Tour of the facility was conducted with the facility designated Administrator Jessica Sanchez.
Dining area, living areas, and all other areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility kitchen was conducted.
Food storage was reviewed to make sure that this facility maintained the appropriate 2-day perishable and 7-day nonperishable quantities at all times. Additional freezer units were observed to be present and observed to contain additional food items such as bread and other food products.
Medication carts were observed to be used at this time. Policies and procedures were discussed with the facility designated Administrator in regards to handling, dispensing, and proper documentation of the resident medications. Medication carts were observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in facility office, was observed to be present and contained all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/15/2022 by the local fire extinguisher company, Gateway Fire Equipment, and in compliance at this time.
A tour of the facility resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Laundry room and area intended for washing, folding, and preparing the clothes and linens for the residents was toured.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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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: 11/30/2022
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Linens were observed to be present and sufficient to meet the needs of the residents at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence/wall, side gates, and exits was conducted.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

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

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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