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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000839
Report Date: 01/05/2022
Date Signed: 01/05/2022 04:25:03 PM

Document Has Been Signed on 01/05/2022 04:25 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MARY FRANCES HAT RESIDENTIAL FACILITYFACILITY NUMBER:
397000839
ADMINISTRATOR:LAURA REEVESFACILITY TYPE:
740
ADDRESS:14381 E. SARGENT ROADTELEPHONE:
(209) 334-6454
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 5DATE:
01/05/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kathy Moore, Executive AssistantTIME COMPLETED:
10:35 AM
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On 01/05/2022 at 9:00am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Executive Assistant Kathy Moore and Director, Laura Reeves. LPA explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

LPA observed smoke detectors is interconnected with the fire department. Carbon monoxide is in operating condition. Fire extinguisher was last serviced on 02/18/2021. LPA observed mitigation plan completed. First aid kit observed to be complete. Fire drill was last conducted on 12/02/2021.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.

Exit interview conducted with Director and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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