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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701187
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:06:11 PM

Document Has Been Signed on 09/15/2022 01:06 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:WELCOME HOMEFACILITY NUMBER:
502701187
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:1602 CHARLOTTESVILLE LANETELEPHONE:
(209) 312-9352
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 6CENSUS: 0DATE:
09/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Brandi VargasTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived announced to conduct a Pre-licensing inspection. LPA met with applicants Brandi & Jamie Vargas and explained the reason for the visit. The facility is licensed to serve a capacity of 6 residents.

LPA was allowed entry into the facility. There are no residents at this time. LPA, and applicants toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. Facility has required (7) seven- day non-perishable and (2) day- perishable supply of food.

LPA observed furniture and lighting of bedrooms, bathrooms and common areas during this visit. The temperature inside the facility measured at 71*F which is within the required range of 68-85*F. The hot water temperature was measured 120.0*F which is within the required range of 105-120*F.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Facility has central heating and air. LPA observed there is a centrally stored medications area locked and inaccessible to residents.

LPA conducted the Component III during this visit. License pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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