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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700910
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:37:12 PM

Document Has Been Signed on 10/06/2021 01:37 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:CLOVE CARE, LLCFACILITY NUMBER:
342700910
ADMINISTRATOR:RIGONAN, ARVIN JAYFACILITY TYPE:
735
ADDRESS:14 CLOVE COURTTELEPHONE:
(916) 690-7445
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 4CENSUS: 0DATE:
10/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:ARVIN RIGONAN - LICENSEE/ADMINISTRATORTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to the facility to conduct a Required Annual visit. LPA met with the Administrator Arvin Rigonan. Administrator certificate expires 12/26/2021.

No clients at this time.

LPA and Administrator toured physical plant inside and outside to ensure safety for the residents, and all passageways are clear and free of hazards. The fire extinguisher was not in compliance and expires 2/5/2022. Facility also has a pull alarm system.

The hot water temperature was measured at 108.2 F which is within the required range of 105*F to 120*F.

The first aid kit contained the required items such as scissors, tweezers, thermometer, and guide.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed and cited. Exit interview held, copy of report given.

Licensee stated Alta Regional Center is going to complete the vendorization process approximately by the end of October 20212.

Exit interview with Licensee and a copy of report was left.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
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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