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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037000596
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:36:50 PM

Document Has Been Signed on 05/10/2024 03:36 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:C & G RESIDENTIAL CARE HOMEFACILITY NUMBER:
037000596
ADMINISTRATOR/
DIRECTOR:
LIVELY, GLORIAFACILITY TYPE:
735
ADDRESS:514 SUTTER LANETELEPHONE:
(209) 274-2695
CITY:IONESTATE: CAZIP CODE:
95640
CAPACITY: 3CENSUS: 2DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:49 PM
MET WITH:Gloria LivelyTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 5/10/24, at 1:49pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility to conduct their required annual visit. LPA met with Gloria Lively, administrator, and explained the purpose of the visit. Today's visit, there were 2 clients in care with 2 staff on duty.

LPA Villanueva and Licensee/Administrator Gloria Lively toured/inspected the care home to ensure compliance with Title 22 regulations. Observed were 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 107 degrees Fahrenheit and room temperature was observed to be at 74 degrees F.

LPA Villanueva inspected the kitchen area. LPA observed there are 2- days worth of perishable and 7- days non-perishable food supply is maintained. LPA observed carbon dioxide monitor located in the kitchen. LPA observed toxins inside the home to be locked away and inaccessible to clients. Smoke detectors were tested and are operational. Fire extinguishers were last serviced on 11/24/2023. First aid kit are maintained and ready for emergency use. Care home also conducts monthly fire/disaster drills.

LPA Villanueva inspected medication storage and found medications to be locked away and inaccessible to clients. 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 was held with administrator, Gloria Lively, and copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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