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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037000596
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:00:10 PM

Document Has Been Signed on 04/14/2022 03:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:C & G RESIDENTIAL CARE HOMEFACILITY NUMBER:
037000596
ADMINISTRATOR:LIVELY, GLORIAFACILITY TYPE:
735
ADDRESS:514 SUTTER LANETELEPHONE:
(209) 274-2695
CITY:IONESTATE: CAZIP CODE:
95640
CAPACITY: 3CENSUS: 2DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Gloria Lively - AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual Inspection Visit. LPA met with Licensee/Administrator and stated purpose of visit. Administrator Certification # 6002250735 expires 04/13/2023 for Administrator.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. This is a Level 3 Valley Mountain Regional Center vendorized home. The facility currency has 2 clients. There are two clients in one bedroom, respite client room, and two bathrooms available for clients. LPA observed bedrooms to be properly furnished with appropriate lighting. There is a living room, family room, and fenced backyard area. The bathrooms were in sanitary condition, properly maintained and the hot water temperature was observed to be 109.5 degrees Fahrenheit which meets the 105 degree Fahrenheit -120 degree Fahrenheit regulation.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed there are two days worth of perishable and 7 days of non-perishable food supply on hand. LPA observed toxins inside the home to be locked away and inaccessible to clients. Smoke detectors were tested and are operational and care home also has a carbon monoxide detector. Fire extinguishers and first aid kit are maintained and ready for emergency use. Care home also conducts monthly fire/disaster drills, last one March 5, 2022.

LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed all client records for completeness and accuracy. All clients have a current IPP/Needs and Service plan in file. Care home staff also has criminal record clearances and current first aid training on file.

No deficiencies were identified on this inspection.
Exit interview held and copy of report given at the conclusion of this visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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