045920148-12-12-2024-59-AS-RKNT-DBVQAE-20241212105950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045920148
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:01:00 AM

Document Has Been Signed on 12/12/2024 11:01 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GOLD CITY ARF		FACILITY NUMBER:	045920148
ADMINISTRATOR/ DIRECTOR:	BOOTHE, JESSIE		FACILITY TYPE:	735
ADDRESS:	980 HIGH STREET		TELEPHONE:	(530) 888-5000
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY: 6		CENSUS: 0	DATE:	12/12/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Jessie Booth - administrator		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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12/12/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with Safaratu Okono Director of Programs, Aaron Olivia facility manager, administrators Simonie Webster, and Jessie Boothe, and Michelle Frase Chief of Staff and explained the purpose of the visit.

Administrator waived COMP III presentation as they have been operating multiple facilities for several years.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has received fire clearance for six (6) ambulatory clients. The facility has four (4) client bedrooms, and two (2) bathrooms. LPA observed a kitchen table and seating for six in the dining room. LPA observed a couch and two love seats in the living room with ample seating for clients.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave, and refrigerator were all present and working.

The facility has 1 fully charged fire extinguisher which has been inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. First aid kit is stocked and available for use.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLD CITY ARF	FACILITY NUMBER: 045920148
	VISIT DATE: 12/12/2024

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Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. The facility has a linen closet which contains towels and face cloths. Bathrooms were observed to be in good repair.

Storage and lighting are adequate in the home. Medications are to be stored in a locked cabinet. Cleaning supplies and toxins are locked up in a cabinet in the laundry room. Knives are secured in a locked cabinet. Washer and dryer observed in place and ready for use.

There is a locking office space where client and staff files will be stored.

The front yard has a covered porch for the clients to use. The back yard a patio, multiple shade trees, and a designated smoking area for the clients. There are no pools or bodies of water on the premises.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

Exit Interview and copy of report was provided to administrator Jessie Boothe.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

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