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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701297
Report Date: 09/16/2024
Date Signed: 09/16/2024 01:39:18 PM

Document Has Been Signed on 09/16/2024 01:39 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:G STREET HOUSE BOARD AND CAREFACILITY NUMBER:
342701297
ADMINISTRATOR/
DIRECTOR:		GAVINO, NELIE M.FACILITY TYPE:
735
ADDRESS:1700 G STREETTELEPHONE:
(916) 447-2748
CITY:SACRAMENTOSTATE: CAZIP CODE:
95811
CAPACITY: 14CENSUS: 14DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nelli GavinoeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPAs Moleski and Williams met with facility administrator Nelie Gavino and explained the purpose of the visit.

LPAs Moleski and Williams reviewed 6 resident files (R1-R6) and 5 staff files (S1-S5).

LPAs Moleski and Williams toured the facility with Gavino inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 110 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPAs Moleski and Williams observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPAs Moleski and Williamsobserved a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. However, LPAs Moleski and Williams observed several bowls of food that were uncovered in the refrigerator. LPAs Moleski and Williams observed a locked cabinet for the storage of medication. LPAs Moleski and Williams observed locked cabinets for the storage of cleaning solutions and knives. In the kitchen, LPAs Moleski and Williams observed a unlocked drawer with two pairs of sharp pruning shears. LPA Williams checked 3 residents P and I ledgers and the balances were correct.

LPAs Moleski and Williams observed during record review that a needs and services plan was missing from R3's file. R3's admission date is 12/31/2022.

LPAs Moleski and Williams interviewed one staff member (S1) and 4 residents (R1-R3 and R8). [continued on 809-C]
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: G STREET HOUSE BOARD AND CARE
FACILITY NUMBER: 342701297
VISIT DATE: 09/16/2024
NARRATIVE
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This facility is being cited per 22 CCR sections 80087(g), 80076(a)(14), and 85068.2(b).

An exit interview was held with Gavino. Appeal rights and a copy of this report were left with Gavino.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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Document Has Been Signed on 09/16/2024 01:39 PM - It Cannot Be Edited


Created By: Holly Williams On 09/16/2024 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: G STREET HOUSE BOARD AND CARE
FACILITY NUMBER: 342701297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not keep sharp objects locked up in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Licensee locked up all sharp object that were unlocked. This Plan of Correction (POC) will be cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Holly Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/16/2024 01:39 PM - It Cannot Be Edited


Created By: Holly Williams On 09/16/2024 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: G STREET HOUSE BOARD AND CARE
FACILITY NUMBER: 342701297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(14)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (14) All foods or beverages capable of supporting rapid and progressive growth of microorganisms which can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not cover several bowls of food in the refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Licensee corrected the uncovered food during the inspection. This POC will be cleared.
Type B
Section Cited
CCR
85068.2(b)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not have a needs and serves plan for R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee agrees to provide LPA Williams email Holly.Williams@dss.ca.gov a copy of the needs and services plan for R3.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Holly Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


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