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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557004883
Report Date: 08/21/2023
Date Signed: 08/21/2023 11:03:17 AM

Document Has Been Signed on 08/21/2023 11:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WATCHFACILITY NUMBER:
557004883
ADMINISTRATOR:CLINT BOWERFACILITY TYPE:
775
ADDRESS:12801 CABEZUT ROADTELEPHONE:
(209) 533-0510
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 140CENSUS: 59DATE:
08/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Mica Stone - Director of Program ServicesTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual visit. LPA met with director of program services and explained purpose of visit. There are currently 59 clients receiving services at this time

LPA and director of program services inspected the interior and the exterior of the facility including the common activity areas, medication storage, kitchen, and outdoor areas. The facility areas observed were clean and in good repair. There is a locked storage for medications. The hot water temperature was measured at 113.2*F which is within the required range of 105-120*F.

Fire extinguishers were last inspected on April 13, 2023. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector and performs disaster drills as required. All Fire Exits are free of obstacles and last fire drill was completed on August 2, 2023. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.
LPA reviewed five staff and five client files. Client emergency contact complete. LPA observed all staff and client files complete. All staff have criminal record clearance and are associated to the facility.

LPA requested the following updated documents for CCL to be submitted via email by September 28, 2023:
LIC 308 Designation of Administrative Responsibility, LIC 309 Administrative Organization, LIC 500 Personnel Report, LIC 610-D the Emergency Disaster Plan, Bylaws, and Articles of Incorporation.
ruth.wallace@dss.ca.gov

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

Exit interview conducted with director of program services. A LIC 811(Confidential Names) and copy of report left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023
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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