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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507202944
Report Date: 11/22/2021
Date Signed: 11/22/2021 01:27:24 PM

Document Has Been Signed on 11/22/2021 01:27 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:TOJINO GUEST HOMEFACILITY NUMBER:
507202944
ADMINISTRATOR:TOJINO, MARISAFACILITY TYPE:
735
ADDRESS:2516 MANOR OAKTELEPHONE:
(209) 765-9735
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:LICENSEE/ADMINISTRATOR - MARISA TOJINOTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced annual required inspection. LPA explained purpose of visit with Administrator. Administrator Certificate #6018369735 expires on 7/22/2022. There are currently 6 residents who reside at this facility.

The LPA toured the facility with the licensee on 11/22/2021 at 12:30 PM. 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 of the facility to ensure compliance with Title 22 regulations.

The facility is sanitary. The facility kitchen has a 2 day perishable and 7 day non-perishable food supply. The facility living room is furnished, and the furniture is in good repair. The facility has a public phone. The facility resident bedrooms are furnished and furniture is in good repair. The facility bathrooms are sanitary, and they are equipped with grab bars, non-slip mats. The facility water temperature is 107.5.

LPA reviewed 3 staff files. Staff files were complete. LPA reviewed 3 resident files. 3 resident files were complete. The facility has first aid kit, which is complete. LPA reviewed 3 medication files. Medication files were complete. Medications are stored in a locked cabinet. Last fire drill was 10/21/2021. Fire extinguishers inspection expire on 8/29/2022. The exterior of the facility is clear of debris. The exterior emergency door is in good repair, and clear of debris.


The following documents needed to be submitted to licensing by January 11, 2022:
Copy of Administrator Certificate, Copy Surety Bond
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Based on observation, interview, and record review, the facility is in compliance with California Code of Regulations, Title 22 Health and Safety Code, there were no deficiencies cited at this time.
Exit interview held with Administrator and a report left at facility..
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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