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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570317743
Report Date: 05/07/2024
Date Signed: 05/07/2024 05:03:25 PM

Document Has Been Signed on 05/07/2024 05:03 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/
DIRECTOR:
SAMANTHA YOUNGFACILITY TYPE:
735
ADDRESS:2525 EAST 8TH STREETTELEPHONE:
(530) 757-1294
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 14CENSUS: 12DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Samantha Young, Administrator and Stacy Sharp, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
05:03 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required inspection and met with Samantha Young, Administrator and Stacy Sharp, Program Manager. There are currently 12 residents at this Adult Residential Facility. There were 8 staff on site at the time of inspection.

LPA conducted a walk-through of the facility and found it to be clean, well-organized and a comfortable temperature between 72-74 F. There were 8 carbon monoxide detectors which are tested monthly. There were 4 fire extinguishers which were fully charged and last serviced on 04/05/2024. The facility had an Emergency Fire Drill on 04/05/2024 for the AM shift; the PM and NOC shift will have a drill later in the quarter. The facility has a central fire sprinkler system Each staff member has First Aid/CPR training. The med room is locked and medications are double-checked prior to being administered. The kitchen was well-stocked and sharps are locked when not in use. There was an ample supply of perishable and non-perishable food, as required in Title 22. Residents' rooms were nicely furnished and included many personal touches.

LPA observed residents returning from Day programs; excited to return home. There was a real sense of community, with residents participating in meal prep and planning, recreational activities, and enjoying social time together.

Exit interview conducted with Samantha Young, Administrator, whose signature on this document confirms receipt.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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