<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001571
Report Date: 10/21/2025
Date Signed: 10/21/2025 03:39:22 PM

Document Has Been Signed on 10/21/2025 03:39 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:RICHBOROUGH FOUNTAIN, INC.FACILITY NUMBER:
347001571
ADMINISTRATOR/
DIRECTOR:		SALVADOR, RYANFACILITY TYPE:
735
ADDRESS:9038 RICHBOROUGH WAYTELEPHONE:
(916) 685-1194
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
10/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Josephine ShobhnaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/21/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA initially met with staff on duty and stated the purpose of the visit. The Facility Manager, Josephine (S1) was notified and arrived shortly after.
Initial Observation: Present upon arrival were 2 residents in care with 2 staff on duty. The other 4 residents were out in the community. Room temperature was at 78 degrees Fahrenheit.
Physical Inspection: Areas inspected include, but not limited to, the resident bedrooms, resident bathrooms, living room, kitchen and dining room and outdoor areas. Rooms #1 & #4 are designated as staff/office; rooms #2, 3, & 5 are shared resident bedrooms. Hot water temperature was taken in the hallway bathroom, at 112 degrees Fahrenheit. Fire extinguishers were observed and last serviced on 5/6/25. Fireplace was screened. Medications, cleaning supplies, sharp objects and other dangerous items were locked and inaccessible to residents in care. Emergency walkways were unobstructed. Shut off valves were located. Fence and gates were in good repair at this time. No bodies of water.
Record Reviews: Review of 3 of 3 resident files, included, but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. 2 resident medications were reviewed. Resident cash was also reviewed for 2 residents. Review of 3 staff files included, but not limited to, review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. LPA also reviewed fire drill/disaster drill records; facility conducts monthly drill. First Aid kit was reviewed and complete at this time. LPA requested a copy of current Liability Insurance Certificate, LIC500, LIC308, and Surety Bond during this visit.
Interviews: LPA interviewed 2 staff (S1 and S2). Residents present during this visits are non-verbal.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Exit interview was conducted. A copy of the report was provided upon exit.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4