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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701194
Report Date: 01/13/2025
Date Signed: 01/14/2025 10:20:23 AM

Document Has Been Signed on 01/14/2025 10:20 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:HOSPITALITY HOUSEFACILITY NUMBER:
502701194
ADMINISTRATOR/
DIRECTOR:		PADILLA, LORRAINEFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 80CENSUS: 43DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator Lorraine Padilla TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with Administrator, Lorraine Padilla and explained the reason for the visit Census: 43

LPA Lund and Administrator Lorraine Padilla toured/inspected the facility. The kitchen was inaccessible to residents and was locked when not staffed. The LPA inspected the food supply and found 2- days of perishable and 7- days of non-perishable. Fire extinguishers were inspected July 12, 2024. LPA also observed a sufficient number of smoke/carbon monoxide detectors to be in compliance. First Aid kit was also inspected and found to be in compliance. LPA inspected the exterior of the building. Gates on either side of the facility were observed to be locked from the inside. LPA inspected the Emergency/Disaster kit and found it to be in compliance at this time. LPA conducted a records review of 4 resident files and 3 Staff files and were in compliance. LPA toured the dining room, living room, resident rooms and all common areas had sufficient furniture, furnishings, and lighting at this time, to be in compliance.

No deficiencies were observed or cited during today's visit. Exit interview held and copy of the report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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