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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701486
Report Date: 10/22/2025
Date Signed: 11/03/2025 11:52:59 AM

Document Has Been Signed on 11/03/2025 11:52 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:LIVEWELL CARE HOME LLCFACILITY NUMBER:
032701486
ADMINISTRATOR/
DIRECTOR:		JONATHAN LIFACILITY TYPE:
735
ADDRESS:290 GOLD STRIKE CTTELEPHONE:
(209) 560-6279
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 4CENSUS: 4DATE:
10/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jonathan LiTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/22/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA met with the Licensee/Administrator, Jonathan Li (AD), and stated the purpose of the visit.

Overview: Facility is a two-story home located in a residential neighborhood. Facility is licensed to serve up to 4 adult residents, ages 18 to 59, all ambulatory only. Facility is also vendored by Valley Mountain Regional Center.

Initial Observation: Upon arrival LPA did not observe any residents during this visit. All residents were out in the community. LPA observed required posters and facility license. Room temperature was at 72 degrees Fahrenheit.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, bedrooms, bathrooms, living and dining room and outdoor areas.
LPA and AD inspected 4 resident bedrooms and 4 resident bathrooms. Upstairs have the 3 resident bedrooms and two bathrooms. Downstairs have 1 resident bedroom, 1 staff room, and two bathrooms. LPA measured the hot water temperature in one of the upstairs bathrooms, it was at 110 degrees Fahrenheit. LPA observed an evacuation chair by the stairs. Facility is equipped with elevator.
Fire extinguishers were observed upstairs and downstairs and were last inspected on 2/13/2025. Smoke and carbon monoxide detectors were observed throughout, tested and found operable at this time. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 10/22/2025
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Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. No bodies of water were observed. There is a generator at the side of the home.
Food Service: Facility maintains at least 7-day non-perishable and 2-day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Proper storage of food items were observed. Kitchen refrigerator and freezer were maintained at regulatory temperature. Additional refrigerator and freezers were observed inside the detached gym and garage area. One of the fridge in the garage is there they store medications that require refrigeration. Garage is locked and not accessible to residents.
Record Reviews: Review of 4 resident records included, but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to update certain records.
Medication review of 2 resident included review of physician orders for over-the-counter medications. Resident cash was also reviewed for 2 residents which AD counted the money on hand.
Review of 5 staff records(AD, S1-S4) included review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. S3 did not complete their health screen prior to employment or 7 days after employment. Advisory was provided to AD to ensure staff records are updated and available for review at any time.
LPA also reviewed fire drill/disaster drill records; facility conducts monthly drill. First Aid Kit was reviewed and found to be complete.
LPA was provided a copy of current Liability Insurance Certificate, Surety Bond, LIC308, LIC500 and LIC610 during this visit.

Interviews: LPA interviewed 1 staff. No resident in care during this visit.

Per the California Code of Regulations, Title 22, Division 6, deficiencies were cited. Exit interview was conducted with AD. A copy of the report and appeal rights were provided upon exit.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2025 11:53 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/22/2025 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIVEWELL CARE HOME LLC
FACILITY NUMBER: 032701486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. One staff member did not complete their health screen prior to or 7 days after employment, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Per Administrator, staff member has an appointment tomorrow 10/23/25 to obtain a health screening from their physician.
Per Administrator, proof of completed health screen will be submitted once completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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