<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701379
Report Date: 09/27/2024
Date Signed: 10/01/2024 09:06:06 AM

Document Has Been Signed on 10/01/2024 09:06 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:VALLEY ROYALE HOME CAREFACILITY NUMBER:
502701379
ADMINISTRATOR/
DIRECTOR:		GENARO R BAISAC JR.FACILITY TYPE:
740
ADDRESS:2628 COLLEGE AVETELEPHONE:
(209) 345-4351
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 2DATE:
09/27/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator Genaro Baisac TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct annual/required visit. LPA Lund met with Administrator Genaro Baisac and explained the reason for the visit. Census: 2

LPA Lund and Administrator Genaro Baisac tour/inspected the facility. LPA inspected the dining area, living area, and all other areas for resident use. LPA observed to be furnished and maintained in compliance at this time. The Facility had a Medication cabinet (locked) were medication is 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. LPA Lund reviewed two staff & two residents files are in compliance.

No deficiencies were cited at this time and copy of report given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1