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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 08/01/2023
Date Signed: 08/01/2023 01:04:51 PM


Document Has Been Signed on 08/01/2023 01:04 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:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR:KARLY STURGEONFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:49CENSUS: 28DATE:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Karly SturgeonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA met with Administrator Karly Sturgeon and explained the purpose of the visit.

LPA and Administrator toured the facility to ensure compliance of Title 22 regulations. The facility has an Assisted Living side and a Memory Care side. Emergency exits were observed to be unobstructed. LPA measured the water temperature in 3 bathrooms. Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 74*F throughout the facility. LPA observed the facility to have adequate food supply. Facility has an emergency food and water kit. Resident rooms were sanitary and had the required furniture and furnishings. Technical assistance was provided for an empty memory care room, which had a mattress that was observed to have cracks in the middle due to long term usage. Administrator was advised that the mattress should be replaced before another resident occupies the room. No foul odors detected throughout facility. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was in good and working condition. LPA observed toxins, medications, and sharps to be locked away and inaccessible to clients. The facility has an outdoor shaded sitting area for residents and visitors located in the front of the facility. In the back of the facility, there is a gardening area, games, and areas for sitting. During the tour, residents were observed to be singing to music, playing balloon toss, being assisted with ADLs, and eating lunch.

LPA reviewed resident files and staff files. LPA observed all files to be up to date with necessary documents. Emergency drills were completed and up to date. LPA spoke to residents and staff during the visit. LPA observed 3 Administrative staff, 1 Laundry staff, 3 Direct Care staff, 1 Medication Technician, 1 Activity Director, 1 Activity Assistance, 1 Maintenance staff, and 3 Kitchen staff. LPA requested and obtained the following documentation: LIC 500, Liability Insurance, LIC 610
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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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