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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700910
Report Date: 01/28/2025
Date Signed: 01/28/2025 02:58:14 PM

Document Has Been Signed on 01/28/2025 02:58 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CLOVE CARE, LLCFACILITY NUMBER:
342700910
ADMINISTRATOR/
DIRECTOR:		RIGONAN, ARVIN JAYFACILITY TYPE:
735
ADDRESS:14 CLOVE COURTTELEPHONE:
(916) 690-7445
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 4CENSUS: 3DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:27 PM
MET WITH:Arvin RigonanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/28/25 at 12:27 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Arvin Rigonan. LPA explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 7010220735 and will expire on 12/26/25. The current census is 3 with 3 facility staff.

This facility is a single story building licensed to serve four (4) ambulatory clients, of which 1 may be non-ambulatory. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 108.3 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 01/28/25. The last fire drill was conducted on 01/05/25. LPA observed the facility has a has a public telephone in the common room and the facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 70 degrees Fahrenheit. LPA observed toxins located under the kitchen sink kept locked and inaccessible to clients. LPA observed sharp knives kept locked and inaccessible to clients. LPA checked medication storage and found medication to be locked away and inaccessible to clients.

Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CLOVE CARE, LLC
FACILITY NUMBER: 342700910
VISIT DATE: 01/28/2025
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 LPA Lee reviewed and compared 2 out of 3 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all of the required components. LPA requested client and staff files for review. LPA reviewed 3 out of 3 client files and 3 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents were given to LPA during today's visit.


(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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