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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295920185
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:02:22 PM

Document Has Been Signed on 12/04/2024 12:02 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:BRAGG HOUSEFACILITY NUMBER:
295920185
ADMINISTRATOR/
DIRECTOR:		GARCIA, DESTINYFACILITY TYPE:
735
ADDRESS:10511 BRAGG AVETELEPHONE:
(530) 477-5965
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 6CENSUS: 6DATE:
12/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Destiny GarciaTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Graham Gunby arrived on Wednesday December 4, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. All files contained the required paperwork. This facility has a fire clearance for 6 (six) residents ranging in age from 18 to 59. Facility has all required postings.

LPAs toured the facility with the Administrator, Destiny Garcia. The following areas were inspected for compliance: kitchen, backyard, resident bedrooms, bathrooms, and common areas. Facility has current fire extinguishers and a full first aid kit. Medications will be kept locked in a secured room. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with administrator and a copy of this report will be left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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