<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005548
Report Date: 03/03/2023
Date Signed: 03/03/2023 01:08:17 PM

Document Has Been Signed on 03/03/2023 01:08 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:BLEVINS HOMEFACILITY NUMBER:
507005548
ADMINISTRATOR:CASEY BLEVINSFACILITY TYPE:
735
ADDRESS:3901 SWEEPSTAKES DRIVETELEPHONE:
(209) 863-9905
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 4CENSUS: 4DATE:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kesha JonesTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/3/23 at approximately 10:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Kesha Jones, House Manager, and explained the purpose of today's visit. The Administrator holds a current Administrator's certificate 6010821735.

LPA Jensen toured the facility and grounds. The grounds were observed to be maintained and free of debris. All paths were observed to be clear. There are no bodies of water on the premises. The facility has adequate outdoor furniture and shade for resident activities. LPA Jensen toured the interior of the facility including but not limited to kitchen, living room, bathrooms, garage. The facility was observed to be sanitary and free of odor. All required signs were posted in locations easily viewed by residents. The facility maintains 2 day supply of perishable food and 7 day supply of non-perishable food. There was no expired food observed. All knives, medications, and chemicals are locked and inaccessible to residents in care. The fire extinguishers were last serviced in October of 2022 and are in compliance. All smoke detectors and carbon monoxide detectors were tested and determined to be in good working order. The facility maintains an emergency food supply and a 30 day supply of PPE. The first aid kit was observed to be complete with scissors, tweezers, thermometer and 1st aid manual. The bedrooms were observed to have all required furniture including chair, dresser, lamps, night stand. There are night lights in the hallways and emergency lighting available.

LPA Jensen reviewed 4 of 4 resident files and found them to be in compliance. LPA Jensen interviewed 1 of 4 clients. 3 of 4 clients were unable to provide interviews. LPA Jensen reviewed 2 staff files and found them to be in compliance. LPA Jensen interviewed 2 of 2 staff.

The facility was found to be in substantial compliance. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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