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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390302236
Report Date: 04/02/2024
Date Signed: 04/02/2024 11:58:50 AM

Document Has Been Signed on 04/02/2024 11:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HUBER'S GUEST HOMEFACILITY NUMBER:
390302236
ADMINISTRATOR:HUBER, RICKYFACILITY TYPE:
735
ADDRESS:18759 N. CHESTNUT ST.TELEPHONE:
(209) 368-8330
CITY:WOODBRIDGESTATE: CAZIP CODE:
95258
CAPACITY: 15CENSUS: 12DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Rick Huber TIME COMPLETED:
12:00 PM
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On 04/02/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Rick Huber and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for 15 ambulatory clients. There are currently 12 clients who reside at this facility.

The LPA Martinez toured the facility with Rick Huber on 04/02/2024 at 11:30 AM.

LPA Martinez reviewed six client files and two employee files. The files were maintained. LPA Martinez reviewed 1 medication administration record (MAR). The MAR was complete. LPA Martinez reviewed infection control plan and natural disaster plan. The last fire drill was on 03/26/24 and the last sprinkler test was on 03/26/2024. The fire extinguishers, smoke detectors, and carbon monoxide detectors were in good repair. The facility common areas were furnished and bedrooms were furnished. The facility has a designated area for laundry services. Medication cart is locked, and the facility has a first aid kit. The facility has an adequate food supply.

Based on today's annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was conducted, and a copy of this report was given to the facility at the end of the visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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