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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001341
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:28:17 PM

Document Has Been Signed on 12/03/2024 12:28 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GRIDLEY ADULT SERVICES PROGRAMFACILITY NUMBER:
045001341
ADMINISTRATOR/
DIRECTOR:
CHERYL CHILDERSFACILITY TYPE:
775
ADDRESS:262 LITTLE AVENUETELEPHONE:
(530) 846-4988
CITY:GRIDLEYSTATE: CAZIP CODE:
95948
CAPACITY: 25CENSUS: 17DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cheryl ChildersTIME VISIT/
INSPECTION COMPLETED:
12:37 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Administrator Cheryl Childers.

An updated fire clearance was completed on 11/07/2024, which has total of 25 clients of which 10 may be non-ambulatory. The main entrance opens to a foyer. To the left of the main entrance leads to two common areas which the larger one has a sliding door to the outside, one full client bathroom, one full staff bathroom, and one office. To the right of the main entrance is the kitchen, a small common room, laundry room, a common half bathroom, and the laundry room has a door leading to the garage. In front of the main entrance is a brick fire place that is blocked off and on the other side of the fire place is another common area. The backyard has a fenced in pool that has a locked gate, a pool house used for storage and has a common bathroom, and further back in the yard is a covered area. The backyard also has a paved area for parking.

During the inspection, LPA observed the fence in the backyard has several areas that were blown down and some slats in the fence are missing. This is a potential issue for the clients because they have access to the backyard for activities.

several client files were reviewed.
staff training and procedures were reviewed.

Multiple topics were discussed during visit.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left

Appeal rights were issued.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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Document Has Been Signed on 12/03/2024 12:28 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 12/03/2024 at 11:48 AM
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: GRIDLEY ADULT SERVICES PROGRAM

FACILITY NUMBER: 045001341

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which the backyard fence has several portions that are blown down and several slats are missing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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By 01/03/2025, the licensee shall come up with a written plan on how they are going to ensure the fence is in good repair. There shall be at minimum a date of when the fence is going to be repaired and shall be submitted as well. If the fence cannot be repaired within 60 days the licensee shall also submit a written plan for monitoring the clients to ensure their safety when outside in the backyard.
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.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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