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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701458
Report Date: 10/31/2024
Date Signed: 11/05/2024 08:57:35 AM

Document Has Been Signed on 11/05/2024 08:57 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:RTG CARE HOMEFACILITY NUMBER:
392701458
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, TINAFACILITY TYPE:
735
ADDRESS:137 CHEYENNE STREETTELEPHONE:
(510) 386-1891
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 4CENSUS: 0DATE:
10/31/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Tina GonzalezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 10/31/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility Applicant, Tina Gonzalez, who was briefly interviewed at this time.
Current census was 0 residents.
It was learned that this facility will be seeking to accept and retain up to (4) ambulatory only residents through vendorization with Valley Mountain Regional Center (VMRC) at any given time.
It was learned that this facility will have a program to be able to accept and retain Level 4I residents at any given time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in the second floor facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located on the second floor, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate for the facility designated Administrator, Tina Gonzalez, was observed to have been completed with certificate number #6070295735 that was set to expire on 05/05/2026 and in compliance at this time.
Medication cabinet, located in the facility hallway closet, was observed to be locked and made inaccessible to
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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: RTG CARE HOME
FACILITY NUMBER: 392701458
VISIT DATE: 10/31/2024
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the residents at this time.
First aid kit, located in the facility medication cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers, located in the first floor kitchen area and second story hallway, was observed to have been recently inspected by the local fire authority, Nor Cal Fire Inc, on 05/29/2024 and in compliance at this time.
Facility resident bedrooms, all located on the second floor, were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms, (2) located on the second floor, were toured.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.

Component III was conducted with the facility Applicant, Tina Gonzalez, at this time.

This facility was found to be in compliance at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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