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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557001183
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:16:19 PM

Document Has Been Signed on 10/25/2022 03:16 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:VALLEY OAKS FAMILY HOMEFACILITY NUMBER:
557001183
ADMINISTRATOR:MONA B. GASKILLFACILITY TYPE:
735
ADDRESS:16649 ANDERSON ROADTELEPHONE:
(209) 928-1196
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 8CENSUS: 8DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mona Gaskill - Licensee/AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Inspection Visit. LPA met with administrator and explained the purpose for today's visit. Administrators Administrator's Certification expires 02/25/2023. There are currently 8 residents who reside at this home.

LPA and Licensee inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity areas, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2 day perishable and 7 day nonperishable.

Fire extinguishers were inspected 9/6/22 . Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109.2 degrees which is within the required range of 105-120*F. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

LPA reviewed 2 Staff and 2 Resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

Exit interview conducted with Licensee and a copy of report left at facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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