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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005548
Report Date: 05/01/2024
Date Signed: 05/08/2024 09:45:16 AM

Document Has Been Signed on 05/08/2024 09:45 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLEVINS HOMEFACILITY NUMBER:
507005548
ADMINISTRATOR/
DIRECTOR:		CASEY BLEVINSFACILITY TYPE:
735
ADDRESS:3901 SWEEPSTAKES DRIVETELEPHONE:
(209) 863-9905
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 4CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Kesha JonesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Unannounced Plan of Correction visit made out to this facility on 05/01/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated House Manager Kesha Jones. A brief interview was conducted with the facility designated House Manager at this time.
Current census was 4 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 03/25/2024 and to follow up on the Plan of Correction. The following deficiencies were observed and cited on 03/25/2024:
  • All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

  • 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 facility did complete the Plan of Correction and provided all of the required forms and documents at this time.

Plan of Correction clearance letters were printed and copies were provided to the facility designated Administrator at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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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