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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000780
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:00:08 PM


Document Has Been Signed on 11/30/2023 12:00 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:GLADDING RIDGEFACILITY NUMBER:
317000780
ADMINISTRATOR:KRISTINE REYMONTFACILITY TYPE:
740
ADDRESS:1660 THIRD STREETTELEPHONE:
(916) 645-0106
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:99CENSUS: 32DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Patrick DoppelmayrTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday November 30, 2023 to conduct a case management visit due to an incident report received on 10/23/2023.

LPA discussed R1 with the interim Executive Director, Wellness DIrector, and Resident Care Director. LPA obtained copies of R1's physicians report, physician orders, last home health documentation, and care plan.

Facility will keep LPA updated if R1 returns to the facility.

No deficiencies cited. Exit interview conducted
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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