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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701394
Report Date: 04/19/2024
Date Signed: 04/22/2024 12:46:59 PM

Document Has Been Signed on 04/22/2024 12:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AD1 RESIDENTIAL CAREFACILITY NUMBER:
392701394
ADMINISTRATOR/
DIRECTOR:		DE LARA, CECILFACILITY TYPE:
740
ADDRESS:555 DEERWOOD AVENUETELEPHONE:
(415) 583-5255
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 0DATE:
04/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cecil de Lara, Chai and Orchid DamichobTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Announced Prelicensing visit made out to this facility on 04/19/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility Applicants, Chai and Orchid Damichob, who were briefly interviewed. This LPA later met another facility staff person, Cecil De Lara, who will be the facility designated Administrator.
Current census was 0 residents.
It was learned that this facility will be seeking to accept and retain up to (5) residents under the care of hospice at any given time.
It was learned that this facility will have a program to be able to accept and retain dementia resident at any given time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility employee office, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located in the garage area, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, # 6066497740, for Cecil De Lara was observed to have an expiration date of 03/21/2025 and in compliance at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AD1 RESIDENTIAL CARE
FACILITY NUMBER: 392701394
VISIT DATE: 04/19/2024
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Medication cabinet, located in the facility kitchen area, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the kitchen cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Armor Fire, on 01/21/2024 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. This LPA observed an additional storage shed that were present on the north side of this facility at this time. This storage shed was observed to be locked and made inaccessible to the residents at this time.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

This facility was found to be in compliance at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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