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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701379
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:10:56 PM

Document Has Been Signed on 03/21/2024 03:10 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:VALLEY ROYALE HOME CAREFACILITY NUMBER:
502701379
ADMINISTRATOR:GENARO R BAISAC JR.FACILITY TYPE:
740
ADDRESS:2628 COLLEGE AVETELEPHONE:
(209) 345-4351
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 0DATE:
03/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:applicant, Genaro Baisac Jr.TIME COMPLETED:
03:15 PM
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Announced prelicensing visit was made by LPA Lund. LPA Lund met with applicant, Genaro Baisac Jr. and explained the reason for the visit. Census: 0

The facility will be licensed to serve up to (6) residents at any given time. This Applicant is seeking a facility with six nonambulatory residents. LPA Lund and applicant Genaro Baisac Jr. tour/inspected the facility. LPA inspected the dining area, living area, and all other areas intended for resident use. LPA observed to be furnished and maintained in compliance at this time. The Facility had a Medication cabinet (locked) were medication will be stored. First aid kit was observed in the Medication cabinet to be present and contained all required components at this time. A tour of the (3) resident bedrooms, was conducted all three rooms will be shared. Furnishings intended for use by the residents were observed to meet the needs of the residents at this time. The facility also had one bathroom for the residents. The facility has two rooms for staff use.

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. The facility has a swimming pool which is locked. The facility has two fire extinguishers that and carbon monoxide are in compliance. The has a working telephone.

This facility has been found to be in compliance at this time.
Genaro Baisac Jr. completed the Component 111 requirements and Mitigation Plan.
Exit interview and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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