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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507202944
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:31:19 PM

Document Has Been Signed on 03/14/2024 03:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 5DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marisa TojinoTIME COMPLETED:
01:30 PM
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On 03/14/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by staff member (SM), Edmund Luzon and explained the purpose of the visit. It was asked at this time to go ahead and call the Facility Designated Administrator (FDA), Marisa Tojino, to inform her that CCL was present. There was one other staff member present, Tiffany Rendon. Shortly after, FDA Marisa Tojino arrived at the facility. This facility is currently licensed to hold 6 residents and is vendorized by Valley Mountain Regional Center to hold and accept Level 4 residents at this time. A brief interview was conducted with FDA Tojino.

Current census was 5. A brief interview with FDA Tojino was conducted.

LPA reviewed 6 staff files. 6 out of 6 staff files are up to date. LPA reviewed 3 resident files. 3 out 3 resident files were current and up to date. The Facility Designated Administrator (FDA) has a current administrator certificate #6023095735 and expires on 12/28/2024.

A tour of the facility was conducted.
LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour with FDA Tojino was conducted. Fire extinguisher located in the hallway was serviced by Assured Fire Service Company on 08/17/2023.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TOJINO GUEST HOME
FACILITY NUMBER: 507202944
VISIT DATE: 03/14/2024
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A tour of the garage was conducted. Additional storage for supplies were identified. Additional food supply was identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
A tour of the 3 resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of two staff bedrooms were also conducted.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

A technical violation was provided today for 80070(a) and 80087(a).

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview was conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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