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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570317743
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:40:02 PM

Document Has Been Signed on 09/23/2022 03:40 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DAVIS SUMMER HOUSEFACILITY NUMBER:
570317743
ADMINISTRATOR:JULIE HUNTERFACILITY TYPE:
735
ADDRESS:2525 EAST 8TH STREETTELEPHONE:
(530) 757-1294
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 14CENSUS: 10DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michael Yuen-Hurwitz, Program ManagerTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and investigate the protocols for releasing medications to family/care team for extended visits.

The facility was clean and a comfortable temperature. Residents were interactive and involved in activities at the time of inspection. Staff were supporting residents and getting ready to administer medications (which included a med count).

LPA spoke with Michael Yuen-Hurwitz, Program Manager regarding the practice of sending medications home when residents go for visits. He reported that meds are counted by two staff to verify and re-verify that the count is accurate. Meds are sent home in their original containers for family/careperson to administer. Meds are then recounted upon return of the resident. If there are any discrepancies in count they are discussed with care team/family at that time.

LPA reviewed this report with Program Manager and left a copy.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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