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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701351
Report Date: 02/21/2025
Date Signed: 02/24/2025 07:37:32 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/24/2025 07:37 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:CELY'S CARE HOME LLCFACILITY NUMBER:
392701351
ADMINISTRATOR/
DIRECTOR:
CECILIA REYESFACILITY TYPE:
740
ADDRESS:2372 BLUE TEES DRIVETELEPHONE:
(209) 986-4632
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:54 PM
MET WITH:C. ReyesTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct an post licensing inspection visit. LPA met with the administrator Cecilia Reyes and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 4. Facility has 4 bedrooms and 2 bathrooms for resident use. 1 extra bedroom is for staff use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 0 ambulatory residents, 4 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved infection control plan in place. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 9-15-24. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. Fire drill was conducted on 1/2025.

During this inspection 4 resident files and 2 staffing files were reviewed for regulatory compliance. All files contained required contents. All staff noted on LIC 500 contained criminal background clearances. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Cecilia Reyes.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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