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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701486
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:32:41 PM

Document Has Been Signed on 11/05/2024 04:32 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:LIVEWELL CARE HOME LLCFACILITY NUMBER:
032701486
ADMINISTRATOR/
DIRECTOR:		LI, JONATHANFACILITY TYPE:
735
ADDRESS:290 GOLD STRIKE CTTELEPHONE:
(302) 893-3498
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 4CENSUS: 4DATE:
11/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Jonathan LITIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 11/5/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conduct their pre-licensing inspection. LPA initially arrived at the facility at 1:20pm but no one was at the facility during this time. LPA contacted Applicant Jonathan Li via phone and stated he will be at the facility in about 1 to 2 hours. However, Jonathan stated a staff will arrive before him and will accommodate the LPA with the tour. Once staff arrived at 3pm, LPA conducted the inspection. Present during today’s visit were 4 residents in care with 1 staff on duty.

This facility is fire cleared to accept/retain 4 ambulatory only residents. This facility was also seeking vendorization through Valley Mountain Regional Center (VMRC) to be able to retain and accept (4) Level 3 residents at any given time.

LPA toured the property with Jonathan Li and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. The facility is a two-story home located in a residential neighborhood. Facility has a working elevator. Furniture and furnishings were sufficient to meet the needs of residents in care. The indoor temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees.

A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Freezer was maintained at 0 degrees F and refrigerator was maintained at 33 degrees F.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LIVEWELL CARE HOME LLC
FACILITY NUMBER: 032701486
VISIT DATE: 11/05/2024
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A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the office area, was observed to be locked and inaccessible to residents in care. Additional medication was observed inside a refrigerator in the garage which is inaccessible to residents in care. Facility currently maintains Medication Administration Record (MAR) to ensure medications are properly administered. First aid kits, located in the medication closet, were observed to be present and contained all of the required components at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. There are 3 resident bedrooms upstairs and 1 resident bedroom downstairs. Furniture and furnishings in bedrooms were observed to be sufficient and able to meet the needs of the residents at this time.
An inspection of the resident restrooms (2 of 4) was conducted and were observed to be in good repair at this time.
Hot water temperatures in 2 bathrooms were measured at 118 degrees F.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. The garage which is locked and inaccessible to residents due to chemicals and sharp stored in the garage. There is an exercise room next to the garage which is accessible to residents in care.
Fire extinguishers were observed in the kitchen area and upstairs hallway, and they were last serviced on 2/14/24.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

LPA conducted component III orientation with Jonathan Li. LPA also reviewed application documents.

The applicant has passed prelicensing. No objections were made to licensure.

An exit interview was held with applicant, Jonathan Li, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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