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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005755
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:58:42 PM

Document Has Been Signed on 11/19/2021 02:58 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:MITCHELL RESIDENTIALFACILITY NUMBER:
507005755
ADMINISTRATOR:SANTOS, JENNIFERFACILITY TYPE:
735
ADDRESS:1900 ROBBIE AVETELEPHONE:
(209) 284-0320
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Adminisrtor Jennifer SantosTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the home to conduct an annual inspection and were met by Administrator’s, Joselyne Montes and Jennifer Santos and explained the reason for the visit. Current Census is 4.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies.

Fire extinguishers and smoke detector are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA observed carbon monoxide detectors in the facility.

No deficiencies were observed during the visit. Exit interview conducted and report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
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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