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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701454
Report Date: 10/07/2024
Date Signed: 10/07/2024 11:36:54 AM

Document Has Been Signed on 10/07/2024 11:36 AM - 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:A GROWING SEED RESIDENTIALFACILITY NUMBER:
392701454
ADMINISTRATOR/
DIRECTOR:		JACKSON, TOPEKAFACILITY TYPE:
735
ADDRESS:4927 SHIPWHEEL DRIVETELEPHONE:
(510) 472-1812
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 0DATE:
10/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Topeka Jackson TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 10/07/2024 at 9:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct a pre-licensing visit. LPA was greeted by applicant, Topeka Jackson and explained the purpose of the visit.
This facility may house 4 ambulatory residents between the ages of 18-59. In addition, this facility is awaiting vendorization from Valley Mountain Regional Center to accept and retain Level 4I residents at this time.

Current census was 0. A brief interview with applicant Jackson was conducted.
The applicant has a current administrator certificate #6069528735 and expires on 12/02/2026.

A tour of the facility was initiated with Applicant Jackson.
A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7 day non-perishable food supply. LPA observed knives and toxins locked and made inaccessible to residents in care. A fire extinguisher was also located in the kitchen and was serviced by the Local Fire Complaint Armor Co on 03/14/2024.
A tour of the back yard was conducted with no hazards present. Perimeter fence and exit gates were observed to be in good repair.
A tour of the living area, dining area, and other areas intended for resident use was conducted. Furniture was observed to be in good repair and meet resident needs.
A tour of 2 bathrooms were conducted. Hot water was taken to ensure compliance within regulation.
A tour a 3 resident bedrooms were conducted. Resident furniture was observed to be in good repair and meet residents needs. An additional staff bedroom was toured.
A tour of the laundry room was conducted. Toxins and other cleaning supplies were identified and made inaccessible to residents in care.
A linen closet located in the hallway was tour and present a sufficient amount of linens to meet the residents needs.
A tour of the garage was conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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: A GROWING SEED RESIDENTIAL
FACILITY NUMBER: 392701454
VISIT DATE: 10/07/2024
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Carbon monoxide and smoke alarms were observed and tested to ensure it was in proper working condition. The facility temperature was at 68.

Based on the observations made during this visit, this applicant has passed the pre-licensing inspection.
Component III was reviewed with this applicant.

An exit interview was conducted and a copy of this report was provided to the applicant at the end of this visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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